Rapid early rise in heart rate on treadmill exercise in patients with asymptomatic moderate or severe aortic stenosis: a new prognostic marker?

ObjectiveTo examine the clinical significance and prognostic value of an early rapid rise in heart rate (RR-HR) in asymptomatic patients with moderate or severe aortic stenosis (AS).MethodsWe retrospectively assessed the prospectively collected data from 306 patients (age 65±12 years, 33% women) with moderate (n=204) or severe AS (n=102) with a median follow-up of 25 months (mean 34.9±34.6 months). All had echocardiography and modified Bruce exercise treadmill tests (ETT). RR-HR was defined as achieving 85% target HR or ≥50% increase from baseline in the first 6 min. The outcome measures were revealed symptoms during ETT, aortic valve replacement (AVR) and all-cause mortality.ResultsRR-HR occurred in 77 (25%) and 64% developed revealed symptoms (postive predictive value 64% and negative predictive value 84%). On univariate Cox regression analyses in patients with severe AS, RR-HR was associated with AVR (HR 3.32, 95% CI 2.03 to 5.45, p<0.001) but not with all-cause mortality (HR 0.04, 95% CI 0.13 to 9.21, p=0.798). In patients with moderate AS, RR-HR was associated with all-cause mortality (HR 2.67, 95% CI 1.09 to 6.56, p=0.032), but not with AVR (HR 1.35, 95% CI 0.92 to 1.98, p=0.127). These associations remained significant in multivariate Cox regression analyses after adjustment for age, sex, hypertension, coronary artery disease, abnormal blood pressure response, Doppler stroke volume and mean pressure gradient (both p<0.001).ConclusionsRR-HR was associated with the development of revealed symptoms. It predicted revealed symptoms on serial ETT, AVR in severe AS and all-cause mortality in moderate AS. RR-HR may be a useful new measure to define risk in AS.

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Exercise testing in patients with asymptomatic moderate or severe aortic stenosis

Heart ◽

10.1136/heartjnl-2018-312939 ◽

2018 ◽

Vol 104 (22) ◽

pp. 1836-1842 ◽

Cited By ~ 24

Author(s):

Sahrai Saeed ◽

Ronak Rajani ◽

Reinhard Seifert ◽

Denise Parkin ◽

John Boyd Chambers

Keyword(s):

Aortic Stenosis ◽

Exercise Testing ◽

Severe Aortic Stenosis ◽

Prognostic Information ◽

Exercise Tests ◽

Serious Adverse Events ◽

Asymptomatic Patients ◽

All Cause Mortality ◽

Exercise Treadmill

ObjectiveTo assess the safety and tolerability of treadmill exercise testing and the association of revealed symptoms with outcome in apparently asymptomatic patients with moderate to severe aortic stenosis (AS).MethodsA retrospective cohort study of 316 patients (age 65±12 years, 67% men) with moderate and severe AS who underwent echocardiography and modified Bruce exercise treadmill tests (ETTs) at a specialist valve clinic. The outcome measures were aortic valve replacement (AVR), all-cause mortality or a composite of AVR and all-cause mortality.ResultsAt baseline, there were 210 (66%) patients with moderate and 106 (34%) with severe AS. There were 264 (83%) events. 234 (74%) patients reached an indication for AVR, 145 (69%) with moderate and 88 (83%) with severe AS (p<0.05). Of the 30 (9%) deaths recoded during follow-up, 20 (67%) were cardiovascular related. In total, 797 exercise tests (mean 2.5±2.1 per patient) were performed. No serious adverse events were observed. The prevalence of revealed symptoms at baseline ETT was 29% (n=91) and was significantly higher in severe AS compared with moderate AS (38%vs23%, p=0.008). Symptoms were revealed in 18%–59% of patients during serial ETT conducted over a follow-up period of 34.9 (SD 35.1) months. The event-free survival at 24 months with revealed symptoms was 46%±4% and without revealed symptoms was 70%±4%.ConclusionsETT in patients with moderate or severe AS is safe and tolerable. Serial exercise testing is useful to reveal symptoms not volunteered on the history and adds incremental prognostic information to baseline testing.

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

European Heart Journal ◽

10.1093/ehjci/ehaa946.1876 ◽

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<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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Abstract 12459: Is Ejection Fraction <50% the Optimal Threshold for Referral for Valve Replacement in Patients With Severe Aortic Stenosis? Impact of Ejection Fraction on Post-Operative Outcome

Circulation ◽

10.1161/circ.130.suppl_2.12459 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Jordi S Dahl ◽

Mackram F Eleid ◽

Hector Michelena ◽

Christopher Scott ◽

Rakesh Suri ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Ejection Fraction ◽

Valve Replacement ◽

Severe Aortic Stenosis ◽

Left Ventricular ◽

Optimal Threshold ◽

Volume Index ◽

Asymptomatic Patients ◽

All Cause Mortality

Introduction: In asymptomatic patients with severe aortic stenosis (SAS), left ventricular (LV) ejection fraction (EF) <50% is generally considered to be the threshold for referral for aortic valve replacement (AVR). Hypothesis: We investigated the importance of LVEF on long-term outcome after AVR in symptomatic and asymptomatic SAS patients and studied whether LVEF < 50% is the optimal threshold for referral for AVR. Methods and Results: We retrospectively identified 2017 patients with SAS (aortic valve area (AVA)<1cm2, mean aortic valve gradient ≥40 mm Hg, or indexed AVA <0.6 cm2/m2) who underwent surgical AVR from January 1995 to June 2009 at our institution. Patients were divided into 4 groups depending on preoperative LVEF (<50% in 300 (15%) patients, 50-59% in 331 (17%), 60-69% in 908 (45%), and ≥70% in 478 (24%)). The primary end-point was all-cause mortality. During follow-up of 5.3±4.4 years, 1056 (52%) died. Five-year mortality rate increased with decreasing LVEF (41% (n=106), LVEF<50%); 35% (n=98), LVEF 50-59%; 26% (n=192), LVEF 60-69%; 22% (n=90), LVEF≥70%, p<0.0001). Compared to patients with LVEF≥60%, patients with LVEF 50-59% had increased mortality (HR 1.58, p<0.001), with a similar risk increase in both symptomatic (HR=1.56, p<0.001) and asymptomatic patients (HR 1.58, p=0.006, Figure). In a Cox regression analysis corrected for standard risk factors, LV mass index, AVA, and stroke volume index, LVEF was predictive of all-cause mortality (HR=0.89 per 10%, p<0.001). When this multivariable analysis was repeated in the subset of 1333 patients with no history of coronary artery disease, LVEF was still associated with all-cause mortality (HR=0.90 per 10%, p=0.009). Conclusion: In patients with SAS undergoing AVR, patients with LVEF 50-59% have also increased mortality compared to patients with LVEF>60%, suggesting that a different LVEF threshold should be used when referring for AVR.

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ST-segment/heart rate hysteresis improves the exercise testing accuracy for coronary artery detection in asymptomatic patients with severe aortic stenosis

Journal of Cardiovascular Medicine ◽

10.2459/jcm.0000000000001081 ◽

2020 ◽

Vol Publish Ahead of Print ◽

Author(s):

Antonio Procopio ◽

Francesco Radico ◽

Joachim Alexandre ◽

Massimo Mapelli ◽

Federico Archilletti ◽

...

Keyword(s):

Heart Rate ◽

Coronary Artery ◽

Aortic Stenosis ◽

Exercise Testing ◽

Severe Aortic Stenosis ◽

Asymptomatic Patients ◽

St Segment ◽

Testing Accuracy ◽

Artery Detection

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Higher acceleration ejection time ratio predicts impaired prognosis in mild to moderate aortic stenosis

European Heart Journal ◽

10.1093/ehjci/ehaa946.1985 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

E Einarsen ◽

D Cramariuc ◽

E Bahlmann ◽

H Midtboe ◽

J.B Chambers ◽

...

Keyword(s):

Heart Failure ◽

Aortic Stenosis ◽

Ejection Fraction ◽

Cardiovascular Events ◽

Cox Regression ◽

Cardiovascular Death ◽

Regression Analyses ◽

Ejection Time ◽

Major Cardiovascular Events ◽

All Cause Mortality

Abstract Introduction Acceleration/ejection time (AT/ET) ratio is a marker of aortic stenosis (AS) severity, and a predictor of outcome in severe AS. The importance of ejection dynamics in mild and moderate AS has been less investigated. Purpose To investigate the impact of increased AT/ET ratio on prognosis in patients with mild-moderate AS. Methods Data from 1635 patients with asymptomatic mild-moderate AS with preserved ejection fraction enrolled in the Simvastatin and Ezetimibe in Aortic Stenosis study was analysed. Covariates of higher AT/ET ratio was identified in linear regression analysis. Outcome was assessed in Cox regression analyses and reported as hazard ratio (HR) and 95% confidence interval (CI) per 1 standard deviation (SD) higher AT/ET ratio. Median follow-up time was 4 years. Results The total study population included 38% female, mean age 67 years and average peak aortic jet velocity was 3.02 m/s. Higher AT/ET ratio was significantly associated with lower ejection fraction, higher LV mass, higher aortic jet velocity, lower systolic blood pressure, low stroke volume index and lower stress-corrected midwall shortening (all p<0.05). In Cox regression analyses, adjusting for these confounders including age and gender, 1 SD higher AT/ET ratio predicted a 29% increase in hazard for major cardiovascular events, 25% for cardiovascular death and hospitalization for heart failure and 23% increase in hazards for all-cause mortality (Table). Conclusion In asymptomatic mild-moderate AS patients free from diabetes and known cardiovascular disease, higher AT/ET ratio was associated with increased risk for major cardiovascular events, cardiovascular death and hospitalization for heart failure and all-cause mortality independent of traditional risk markers. Funding Acknowledgement Type of funding source: None

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Left ventricular twist predicts mortality in severe aortic stenosis

Heart ◽

10.1136/heartjnl-2020-318800 ◽

2021 ◽

pp. heartjnl-2020-318800

Author(s):

Ladina Erhart ◽

Thierry Donati ◽

Shehab Anwer ◽

Matthias Schindler ◽

Miriam Gremminger ◽

...

Keyword(s):

Aortic Stenosis ◽

Cox Regression ◽

Severe Aortic Stenosis ◽

Global Longitudinal Strain ◽

Left Ventricular ◽

Cox Regression Analysis ◽

Ventricular Mechanics ◽

Transcatheter Aortic Valve ◽

Left Ventricular Twist ◽

All Cause Mortality

ObjectiveLeft ventricular (LV) twist is a major component of ventricular mechanics reflecting the helical orientation of cardiac fibres and compensating for afterload mismatch. However, it is not known whether it determines outcome after transcatheter aortic valve implantation (TAVI). This study sought to investigate TAVI-induced short-term changes of LV twist and to define its role in outcome prediction.MethodsA total of 146 patients (median age 81.78 years, 50.7% male) undergoing TAVI for severe aortic stenosis were included. LV rotation and twist were determined by speckle tracking echocardiography within 3 months before and 2 weeks after TAVI. All-cause mortality at 2 years was defined as primary end point.ResultsPatients who survived exhibited a higher apical peak systolic rotation (APSR) (p<0.001), twist (p=0.003) and torsion (p=0.019) pre-TAVI compared with those who died (n=22). Within 2 weeks after TAVI, APSR, twist and torsion decreased in patients who survived (all p<0.001), while no change occurred in those who died. Cox regression analysis showed an association of pre-TAVI APSR (HR 0.92, p=0.010), twist (HR 0.93, p=0.018) and torsion (HR 0.68, p=0.040) with all-cause mortality and an even stronger association of the respective changes after TAVI (∆APSR: HR 1.15, p<0.001; ∆twist: HR 1.14, p<0.001; ∆torsion: HR 2.53, p<0.001). All the parameters determined outcome independently of global longitudinal strain (GLS) and LV ejection fraction (LVEF).ConclusionAPSR, twist and torsion pre-TAVI as well as their change within 2 weeks after TAVI predict 2-year all-cause mortality after TAVI, adding incremental prognostic value to LVEF and GLS.

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