P3364Cardiac damage in a real-world severe aortic stenosis population

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.

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

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&lt;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

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

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.

scholarly journals The signifi cance of global longitudinal strain of left ventricular in the classifi cation of stages of aortic stenosis based on the extravalvular cardiac damage

2021 ◽  
Vol 99 (3) ◽  
pp. 187-191
Author(s):  
M. G. Matveeva ◽  
M. N. Alekhin
Keyword(s):  
Aortic Stenosis ◽  
Longitudinal Strain ◽  
Severe Aortic Stenosis ◽  
Systolic Dysfunction ◽  
Global Longitudinal Strain ◽  
Left Ventricular ◽  
Cardiac Damage ◽  
Stage 4 ◽  
The Right ◽  
Stage 1

Severe aortic stenosis (AS) is characterized not only by degenerative changes in the aortic valve but also by extravalvular cardiac damage. Recently, a new staging classifi cation of AS has been proposed based on the extent of cardiac damage, as well as its modifi ed variants with the addition of a measure of global longitudinal strain of the left ventricular (GLS LV), as an earlier predictor of preclinical LV systolic dysfunction.Aim. To evaluate the signifi cance of GLS LV in the staging classifi cation of AS based on the extent of cardiac damage according to a multidisciplinary hospital.Мaterials and methods. 66 patients with severe AS with available GLS LV by speckle tracking echocardiography were selected and analyzed retrospectively.Results. Patients were categorized according to cardiac damage on ECHO: stage 0 was determined in 2 (3%) patients; stage 1 — 10 (15%), stage 2 — 41 (62%), stage 3 — 13 (20%). The use of staging classifi cation of AS with addition of GLS LV quintiles led to patient reclassifi cation. Thus, stage 4 included patients from stage 2 and stage 3 cardiac damage.Conclusions. In patients with severe AS, the adding the GLS LV to the routine ECHO can help to more accurately determine the stages of AS and make the right decision on the management tactics of such patients.

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

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
C Silva ◽  
S Maltes ◽  
P Freitas ◽  
A.M Ferreira ◽  
R.C Teles ◽  
...  
Keyword(s):  
Survival Analysis ◽  
Aortic Valve ◽  
Aortic Stenosis ◽  
Real World ◽  
Cox Regression ◽  
Severe Aortic Stenosis ◽  
Staging System ◽  
Cardiac Damage ◽  
All Cause Mortality ◽  
Stage 1

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&lt;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

scholarly journals 615 Symptomatic status and outcomes in a real-world severe aortic stenosis population

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
R Ventura Gomes ◽  
J Pais ◽  
A R Pereira ◽  
D Sebaiti ◽  
I Cruz ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Adverse Events ◽  
Aortic Stenosis ◽  
Real World ◽  
Primary Outcome ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Systolic Pulmonary Artery Pressure ◽  
Aortic Valve Area ◽  
Formal Indication

Abstract Introduction Aortic stenosis (AS) is one of the most common valvular heart diseases and is now frequently diagnosed in asymptomatic patients (AP). Symptomatic patients (SP) have a higher risk of adverse events, in contrast with AP. The current guidelines recommend aortic valve replacement (AVR) for SP with severe AS (SAS), with a very poor prognosis for those conservatively managed. Purpose To evaluate the baseline characteristics, therapeutic strategies and the long-term outcomes of SP and AP with SAS in a real­-world setting. Methods Retrospective cohort study of AP and SP with SAS (mean transvalvular pressure gradient (MG) &gt; =40 mmHg or a peak transvalvular velocity (PTV) &gt; =4.0 m/s), who were examined in our echo lab between January 2014 and December 2016. Follow-up was 2.6 ± 1.0 years. The primary outcome was a composite of cardiovascular death or heart failure hospitalization. Results 212 patients (pts) with SAS were included (age 76.1 ± 9.1years, 31.6% men; aortic valve area 0.69 ± 0.21cm2; PTV 4.5 ± 0.4m/s; MG 48.5 ± 11.6mmHg; left ventricular ejection fraction 58.8 ± 12.2%). 154 pts (72.6%) had symptoms related to aortic stenosis. The SP had higher PTV (4.6 ± 0.5 vs 4.3 ± 0.4m/s, p &lt; 0.0001) and MG (50.4 ± 12.2 vs 43.5 ± 7.8mmHg, p &lt; 0.0001), less peripheral artery disease (2.6% vs 12.1%, p = 0.011), more chronic obstructive pulmonary disease (13.0% vs 1.8%, p = 0.016) and arterial hypertension (74.0% vs 56.0%, p = 0.016). AVR (surgical n = 99, transcatheter n = 13) was performed in 47.6% (n = 101) SP and 19.0% (n = 11) AP (p &lt; 0.0001), while the remainder with a formal indication (n = 70, 33.0%) were managed conservatively. Twelve AP (36.2%) did not undergo AVR, although they had indication (4 refused, 4 due to comorbidities and 4 died). The AVR was not performed in the SP group mostly due to comorbidities (n = 23, 14.9%) and refusal (n = 22, 14.3%). Forty-four pts (20.8%) had at least one event of the primary outcome and there were no differences in the SP and AP groups (n = 36, 23.4% in SP vs n = 8, 13.4% in AP, p = 0.125). However, SP and AP who underwent to AVR had fewer events (Figure 1). Pts with at least one event were mainly female (54.5%, p = 0.026), hadn’t performed AVR (84.1% vs 15.9%, p &lt; 0.0001), had a lower estimated glomerular filtration rate (58.4 ± 21.2 vs 66.3 ± 21.4mL/min/1.73m2, p = 0.03), higher systolic pulmonary artery pressure (45.4 ± 17.3 vs 37.8 ± 14.9mmHg, p = 0.016) and lower TAPSE (20.2 ± 4.9 vs 22.4 ± 4.2mm, p = 0.012). In the multivariate analysis, only the AVR was predictive of the outcome (HR 0.079, CI 0.028-0.227, p &lt; 0.0001). Conclusion In a real-world experience, SAS has a high rate of adverse events. Few differences were observed between SP and AP. The AVR had a significant impact in the outcome, regardless of symptoms, thus implying that selected AP may as well benefit from this intervention. Nonetheless, in a real-world setting, more than one-third of the pts with a formal indication for intervention was conservatively treated. Abstract 615 Figure 1 Survival of SAS pts.

Novel staging classification of primary mitral regurgitation based on the presence of cardiac damage

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
A.L Van Wijngaarden ◽  
Y.L Hiemstra ◽  
P Van Der Bijl ◽  
V Delgado ◽  
N Ajmone Marsan ◽  
...  
Keyword(s):  
Mitral Regurgitation ◽  
Kidney Function ◽  
Left Ventricular ◽  
Prognostic Impact ◽  
Cardiac Damage ◽  
Stage 4 ◽  
All Cause Mortality ◽  
Primary Mitral Regurgitation ◽  
Stage 1 ◽  
Staging Classification

Abstract Background The indication for surgery in patients with severe primary mitral regurgitation (MR) is currently based on the presence of symptoms, left ventricular (LV) dilatation and dysfunction, atrial fibrillation and pulmonary hypertension. The aim of this study was to evaluate the prognostic impact of a new staging classification based on cardiac damage including the known risk factors but also including global longitudinal strain (GLS), severe left atrial (LA) dilatation and right ventricular (RV) dysfunction. Methods In total 614 patients who underwent surgery for severe primary MR with available baseline transthoracic echocardiograms were included. Patients were classified according to the extent of cardiac damage (Figure): Stage 0-no cardiac damage, Stage 1-LV damage, Stage 2-LA damage, Stage 3-pulmonary vasculature or tricuspid valve damage and Stage 4-RV damage. Patients were followed for all-cause mortality. Results Based on the proposed classification, 172 (28%) patients were classified as Stage 0, 102 (17%) as Stage 1, 134 (21%) as Stage 2, 135 (22%) as Stage 3 and 71 (11%) as Stage 4. The more advanced the stage, the older the patients were with worse kidney function, more symptoms and higher EuroScore. Kaplan-Meier curve analysis revealed that patients with more advanced stages of cardiac damage had a significantly worse survival (log-rank chi-square 35.2; p&lt;0.001) (Figure). On multivariable analysis, age, male, chronic obstructive pulmonary disease, kidney function, and stage of cardiac damage were independently associated with all-cause mortality. For each stage increase, a 22% higher risk for all-cause mortality was observed (95% CI: 1.064–1.395; p=0.004). Conclusion In patients with severe primary MR, a novel staging classification based on the extent of cardiac damage, may help refining risk stratification, particularly including also GLS, LA dilatation and RV dysfunction in the assessment. Funding Acknowledgement Type of funding source: None

scholarly journals IMPULSE: the impact of gender on the presentation and management of aortic stenosis across Europe

Open Heart ◽  
2021 ◽  
Vol 8 (1) ◽  
pp. e001443
Author(s):  
Richard Paul Steeds ◽  
David Messika-Zeitoun ◽  
Jeetendra Thambyrajah ◽  
Antonio Serra ◽  
Eberhard Schulz ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Severe Aortic Stenosis ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Surgical Aortic Valve Replacement ◽  
Ventricular Ejection Fraction ◽  
Patient Profile ◽  
Transcatheter Aortic Valve ◽  
The Impact

AimsThere is an increasing awareness of gender-related differences in patients with severe aortic stenosis and their outcomes after surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI).MethodsData from the IMPULSE registry were analysed. Patients with severe aortic stenosis (AS) were enrolled between March 2015 and April 2017 and stratified by gender. A subgroup analysis was performed to assess the impact of age.ResultsOverall, 2171 patients were enrolled, and 48.0% were female. Women were characterised by a higher rate of renal impairment (31.7 vs 23.3%; p<0.001), were at higher surgical risk (EuroSCORE II: 4.5 vs 3.6%; p=0.001) and more often in a critical preoperative state (7.0vs 4.2%; p=0.003). Men had an increased rate of previous cardiac surgery (9.4 vs 4.7%; p<0.001) and a reduced left ventricular ejection fraction (4.9 vs 1.3%; p<0.001). Concomitant mitral and tricuspid valve disease was substantially more common among women. Symptoms were highly prevalent in both women and men (83.6 vs 77.3%; p<0.001). AVR was planned in 1379 cases. Women were more frequently scheduled to undergo TAVI (49.3 vs 41.0%; p<0.001) and less frequently for SAVR (20.3 vs 27.5%; p<0.001).ConclusionsThe present data show that female patients with severe AS have a distinct patient profile and are managed in a different way to males. Gender-based differences in the management of patients with severe AS need to be taken into account more systematically to improve outcomes, especially for women.

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

2014 ◽  
Vol 41 (3) ◽  
pp. 273-279 ◽  
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 (&gt;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 &lt;1.5 cm2), or severe stenosis (&lt;1 cm2). Severe aortic stenosis was further classified by mean gradient (LGAS, mean &lt;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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