End-systolic wall stress in aortic stenosis: comparing symptomatic and asymptomatic patients

AimsIn aortic stenosis (AS), there is poor association between symptoms and conventional markers of AS severity or left ventricular (LV) systolic function. This may reflect that symptoms arise from LV diastolic dysfunction or that aortic valve area (AVA) and transvalvular gradient do not reflect afterload. We aimed to study the impact of afterload (end-systolic wall stress [ESWS]) on the presence of symptoms in AS and to test whether symptoms are related to increased ESWS or LV remodelling.Methods and resultsIn a prospective study, ESWS was estimated by measuring LV wall thickness from MRI and estimated LV end systolic pressure from echocardiographic mean gradient and systolic blood pressure in 78 patients with severe AS scheduled for aortic valve replacement and 91 patients with asymptomatic severe AS. Symptomatic patients had lower indexed AVA (0.40±0.11 vs 0.45±0.09 cm2/m2, p=0.009). They had undergone more extensive remodelling (MRI LV mass index [LVMi]: 85±24 vs 69±17 g/m2, p<0.0001), had higher tricuspid regurgitant gradient (24±8 mm Hg vs 19 ± 7 mm Hg, p=0.0001) and poorer global longitudinal strain (−15.6±3.8 vs −19.9±3.2%, p<0.0001). ESWS was higher among symptomatic patients (96±51 vs 76±25 kdynes/cm2, p=0.003). Multivariate logistic regression identified echocardiographic relative wall thickness, tricuspid gradient, mitral deceleration time, early diastolic strain rate, MRI LVMi, MRI LV end-diastolic volume index and ESWS as independently associated with being symptomatic.ConclusionESWS can be estimated from multimodality imaging combining MRI and echocardiography. It is correlated with LV remodelling and neurohormonal activation and is independently associated with symptomatic status in AS.

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Impact of left ventricular outflow tract flow acceleration on aortic valve area calculation in patients with aortic stenosis

Echo Research and Practice ◽

10.1530/erp-19-0017 ◽

2019 ◽

Vol 6 (4) ◽

pp. 97-103 ◽

Cited By ~ 1

Author(s):

Andaleeb A Ahmed ◽

Robina Matyal ◽

Feroze Mahmood ◽

Ruby Feng ◽

Graham B Berry ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Continuity Equation ◽

Ventricular Outflow Tract ◽

Left Ventricular ◽

Area Measurement ◽

Aortic Valve Area ◽

Flow Acceleration ◽

The Impact ◽

Valve Area

Objective Due to its circular shape, the area of the proximal left ventricular tract (PLVOT) adjacent to aortic valve can be derived from a single linear diameter. This is also the location of flow acceleration (FA) during systole, and pulse wave Doppler (PWD) sample volume in the PLVOT can lead to overestimation of velocity (V1) and the aortic valve area (AVA). Therefore, it is recommended to derive V1 from a region of laminar flow in the elliptical shaped distal LVOT (away from the annulus). Besides being inconsistent with the assumptions of continuity equation (CE), spatial difference in the location of flow and area measurement can result in inaccurate AVA calculation. We evaluated the impact of FA in the PLVOT on the accuracy of AVA by continuity equation (CE) in patients with aortic stenosis (AS). Methods CE-based AVA calculations were performed in patients with AS once with PWD-derived velocity time integral (VTI) in the distal LVOT (VTILVOT) and then in the PLVOT to obtain a FA velocity profile (FA-VTILVOT) for each patient. A paired sample t-test (P < 0.05) was conducted to compare the impact of FA-VTILVOT and VTILVOT on the calculation of AVA. Result There were 46 patients in the study. There was a 30.3% increase in the peak FA-VTILVOT as compared to the peak VTILVOT and AVA obtained by FA-VTILVOT was 29.1% higher than obtained by VTILVOT. Conclusion Accuracy of AVA can be significantly impacted by FA in the PLVOT. LVOT area should be measured with 3D imaging in the distal LVOT.

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P1370 Correlation of aortic stenosis by integrated transthoracic and transesophageal echocardiography with calcium score

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.805 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

Author(s):

S Schwartzenberg ◽

Y Shapira ◽

M Vaturi ◽

M Nassar ◽

A Hamdan ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Stroke Volume Index ◽

Left Ventricular ◽

Low Flow ◽

Volume Index ◽

Left Ventricular Ejection ◽

Aortic Valve Area ◽

Ventricular Ejection Fraction ◽

Coronary Ct

Abstract Funding Acknowledgements None BACKGROUND Aortic stenosis (AS) classification depends on left-ventricular ejection-fraction (LVEF <≥50%), aortic valve area (AVA<≥1cm2), mean pressure gradient (MG<≥40mmHg), peak velocity<≥400 cm/sec, and stroke-volume index (SVI<≥35ml/m2). Aortic Valve Agatston CT score (AVC) correlates with AS severity by trans-thoracic echo (TTE), but its association with AS severity determined by integrated TTE and TEE is unknown. PURPOSE We investigated correlation of AVC with dichotomous AS grouping by Integrated TTE + TEE vs TTE only. METHODS 64 TAVI candidates underwent sequential TTE and TEE, of which 24 underwent coronary CT within 4 months. Based on recommended conservative vs invasive treatment implication (A/B respectively), AS types were aggregated separately by TTE or Integrated TTE-TEE into two groups: Group-A (Moderate AS and Normal-Flow Low-Gradient), and Group-B (High-Gradient, Low-EF Low-Flow Low-Gradient, and Paradoxical Low-Flow Low-Gradient). Continuous and dichotomous AVC correlation (cutoffs based on guidelines) with echo binary classification was then determined. RESULTS Patients were 81.1(77.3-84.6) years old, 18(48.6%) were women, and had LVEF of 60% (49-65). AVC-score distribution in the two AS A/B Groups by two echo modalities is presented in the boxplot Figure. Only classification by TTE held discriminative accuracy in A/B grouping, with Area-Under-Curve of 0.736 (CI 0.57-0.9), and optimal threshold value of 1946 AU having 77% sensitivity and 74% specificity. Compared with AVC dichotomous classification, integrated TTE + TEE upgraded AS class (from A to B) in 5/6 (83.3%) patients vs 12/18 (66.7%) in which it downgraded AS class from B to A. CONCLUSIONS Aortic valve calcification correlates well with AS class dichotomized by operative implication through conventional TTE but not through integrated TTE + TEE. Our preliminary results appear to be caused by initial selection bias of patients in whom coronary CT performance was deemed to be justified by the treating physician rather than reflect a true better correlation between CT score and AS assessment by TTE vs by integrated TTE + TEE. Abstract P1370 Figure.

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Use of passive leg rise as an add-on to dobutamine in patients with paradoxical low-flow, low-gradient aortic stenosis

European Heart Journal ◽

10.1093/eurheartj/ehab724.0120 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

E Buffle ◽

A Papadis ◽

C Seiler ◽

S F De Marchi

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Ejection Fraction ◽

Stroke Volume Index ◽

Left Ventricular ◽

Low Flow ◽

Volume Index ◽

Aortic Valve Area ◽

Low Ejection Fraction ◽

Valve Area

Abstract Background Dobutamine has been proposed for the assessment of low-flow, low-gradient aortic stenosis (LFLGAS). However, in 1/3 of patients, no increase in stroke volume index can be achieved by Dobutamine, thus hampering its diagnostic value. This study evaluated the manoeuvre of cardiac preload augmentation by passive leg rise (PLR) alone or on top of Dobutamine to increase stroke volume index (SVI) in patients with LFLGAS, particularly in paradoxical LFLGAS. Methods We examined 50 patients with LFLGAS. Patients were assigned to the paradoxical LFLGAS (Paradox) group if left ventricular ejection fraction (LVEF) was ≥50% (n=29) and to the LFLGAS with low ejection fraction (LEF) group if LVEF was <50% (n=21). A modified Dobutamine stress echocardiography was performed in all patients with the following 4 steps: Rest, PLR alone, maximal Dobutamine infusion rate alone (Dmax) and Dobutamine plus PLR (Dmax + PLR). Three SVI measurement methods were used: first the left ventricular outflow tract velocity time integral (LVOT VTI) method, second the 2D Simpson's method, and third the 3D method. The corresponding aortic valve area (AVA) was obtained by the continuity equation. The increase of those values compared to measurements at rest was calculated and compared between the 3 stress steps. Results In the paradoxical LFLGAS group, delta SVI with Dmax assessed by both Simpson's (depicted in the figures) and 3D method was lowest compared to PLR and Dmax + PLR. PLR alone yielded an equally high delta SVI as Dmax + PLR in Simpson's and 3D, and was at least as high as Dmax across all methods. Dobutamine alone yielded the lowest delta transaortic aortic valve VTI. The highest delta aortic valve area resulted for Dmax + PLR. In the LEF group, the three stress steps yielded an equally high delta SVI with Simpson's method. Dmax never yielded a higher delta SVI than PLR alone. The yielded delta SVI was the highest for Dmax + PLR for both LVOT VTI and 3d method, although the difference was overall not as strong as in the Paradox group. Conclusions In patients with paradoxical LFLGAS, Dobutamine alone is inadequate for testing the potential of aortic valve opening augmentation. Instead, PLR alone or the addition of PLR plus Dobutamine should be used for that purpose. In low LVEF, adding PLR to Dobutamine also seems useful although its diagnostic added value is less evident than in the Paradox group. FUNDunding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Gottfried und Julia Bangerter-Rhyner-Foundation Paradox group Low ejection fraction group

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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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P303Prognostic value of diastolic wall strain in patients with asymptomatic severe aortic stenosis

European Heart Journal ◽

10.1093/eurheartj/ehz747.0138 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

Y Suwa ◽

Y Miyasaka ◽

N Taniguchi ◽

S Harada ◽

I Shiojima

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Wall Thickness ◽

Severe Aortic Stenosis ◽

Posterior Wall ◽

Left Ventricular ◽

Aortic Valve Area ◽

Kaplan Meier ◽

Posterior Wall Thickness ◽

Diastolic Wall Strain

Abstract Background Diastolic wall strain (DWS) has been reported to be associated with left ventricular (LV) stiffness and worse clinical outcomes. We sought to assess the utility of this new index for prediction of prognosis in asymptomatic patients with severe aortic stenosis (AS). Methods Asymptomatic severe AS patients [peak flow velocity (PFV) ≥4.0m/s, mean pressure gradient (mPG) ≥40mmHg, aortic valve area (AVA) ≤1.0cm2, or indexed AVA ≤0.6cm2/m2)] diagnosed between July 2007 and April 2016 were included in this study. Patients with significant mitral valve disease, posterior wall motion abnormality, prior cardiac surgery, hypertrophic cardiomyopathy, and LV ejection fraction <50% were excluded. DWS was calculated with a validated formula [DWS = (posterior wall thickness at end-systole − posterior wall thickness at end-diastole)/posterior wall thickness at end-systole]. All study patients were prospectively followed up to last visit or death until November 2017, and predictive value of all-cause death was assessed using Cox-proportional hazards modeling. Patients who underwent aortic valve replacement (AVR) during the study period were censored on the date of surgery. Results A total of 184 asymptomatic severe AS, 138 (age 76±9year-old, men 41%, PFV 3.9±1.0m/s, mPG 38±19mmHg, AVA 0.83±0.18cm2, indexed AVA 0.56±0.13cm2/m2) met all study criteria. Of whom, 43 (31%) underwent AVR and 28 (20%) died during a mean follow-up of 25±28months. In a multivariable model after adjusting for clinical and echocardiographic variables, advancing age (per10yrs; HR=2.19, 95% CI=1.19–4.03, P<0.05), history of hemodialysis (HR=4.31, 95% CI=1.30–14.35, P<0.05), and low-DWS (DWS <0.30) (HR=2.83, 95% CI=1.25–6.40, P<0.05) were independent predictors of all-cause death. In the Kaplan-Meier estimates of cumulative survival stratified by DWS status were shown (Figure). The Kaplan-Meier estimates of survival Conclusion Low-DWS provides prognostic information in patients with asymptomatic severe AS.

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Left Ventricular Morphology and Function as a Determinant of Pulmonary Hypertension in Patients with Severe Aortic Stenosis: Cardiovascular Magnetic Resonance Imaging Study

Medicina ◽

10.3390/medicina55100711 ◽

2019 ◽

Vol 55 (10) ◽

pp. 711

Author(s):

Birute Gumauskiene ◽

Lina Padervinskiene ◽

Jolanta Justina Vaskelyte ◽

Audrone Vaitiekiene ◽

Tomas Lapinskas ◽

...

Keyword(s):

Pulmonary Hypertension ◽

Magnetic Resonance ◽

Aortic Valve ◽

Aortic Stenosis ◽

Longitudinal Strain ◽

Severe Aortic Stenosis ◽

Global Longitudinal Strain ◽

Left Ventricular ◽

Volume Index ◽

And Function

Background and Objectives: The influence of cardiac magnetic resonance (CMR) derived left ventricular (LV) parameters on the prognosis of patients with aortic stenosis (AS) was analyzed in several studies. However, the data on the relations between the LV parameters and the development of pulmonary hypertension (PH) in severe AS is lacking. Our objectives were to evaluate the CMR-derived changes of the LV size, morphology, and function in patients with isolated severe AS and PH, and to investigate the prognostic impact of these parameters on elevated systolic pulmonary artery pressure (sPAP). Materials and Methods: Thirty patients with isolated severe AS (aortic valve area ≤1 cm2) underwent a 2D-echocardiography (2D echo) and CMR before aortic valve replacement. Indices of the LV mass and volumes and ejection fraction were analyzed by CMR. The LV global longitudinal (LV LGS) and circumferential strain (LV CS) were calculated using CMR feature tracking (CMR-FT) software (Medis Suite QStrain 2.0, Medis Medical Imaging Systems B.V., Leiden, The Netherlands). The LV fibrosis expansion was assessed using a late gadolinium enhancement sequence. PH was defined as having an estimated sPAP of ≥45 mm Hg. The statistical analysis as performed using SPSS version 23.0 (SPSS, Chicago, IL, USA) Results: 30 patients with severe AS were included in the study, 23% with severe isolated AS had PH (mean sPAP 55 ± 6.6 mm Hg). More severe LV anatomical and functional abnormalities were observed in patients with PH when compared with patients without PH—a higher LV end-diastolic volume index (EDVi) (140 [120.0–160.0] vs. 90.0 mL/m² [82.5–103.0], p = 0.04), larger LV fibrosis area (7.8 [5.6–8.0] vs. 1.3% [1.2–1.5], p = 0.005), as well as lower LV global longitudinal strain (GLS; −14.0 [−14.9–(−8.9)] vs. −21.1% [−23.4–(−17.8)], p = 0.004). By receiver–operating characteristic (ROC) curve analysis, LV EDVi > 107.7 mL/m² (Area Under the Curve (AUC) 95.7%), LV GLS < −15.5% (AUC 86.3%), and LV fibrosis area >5% (AUC 89.3) were found to be robust predictors of PH in severe AS patients. Conclusions: In patients with severe aortic stenosis, a larger end-diastolic LV volume, impaired LV global longitudinal strain, and larger LV fibrosis extent can predict the development of pulmonary hypertension.

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Repeated echocardiographic imaging of aortic stenosis: Real-life lessons

10.22541/au.162012560.03725288/v1 ◽

2021 ◽

Author(s):

Jonathan Bray ◽

Adrian Ionescu

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Intraclass Correlation ◽

Real Life ◽

Stroke Volume Index ◽

Ventricular Outflow Tract ◽

Left Ventricular ◽

Volume Index ◽

Aortic Valve Area ◽

Valve Area

Background Timing of aortic valve intervention is dependent on the accuracy and reproducibility of echocardiographic (ECHO) parameters. We aimed to assess haemodynamic subsets of aortic stenosis (AS), their change over time, and variability of ECHO parameters. Method This retrospective, longitudinal study compared sequential ECHO over 15 months to identify concordant or discordant aortic valve area (AVA) and mean pressure gradient (MPG). Results We included 143 patients with a mean age of 76.0 years. The median length of time between studies was 112 days (IQR 38-208). Initially participants were classified as 10 (7.0%) mild, 49 (34.3%) moderate and 84 (58.7%) severe AS. In 80 (55.9%) AVA and MPG were concordant; stroke volume index (SVi) was <35ml/m2 in 53 (74.6%). AS severity was downgraded in 33 (23.1%) patients. MPG was most consistent and AVA was the least consistent between successive investigations (intraclass correlation coefficients R=0.86 and R=0.76, respectively). Even small variations in left ventricular outflow tract (LVOT) measurement of 1 standard deviation reclassified up to 67% of participants from severe to non-severe. Conclusion Almost half of patients with AS have valve area/gradient discordance. Variations in LVOT diameter measurement commensurate with clinical practice reclassified AS severity in up to 2/3 of cases. Change in AS severity should only be accepted following careful scrutiny of all available ECHO data.

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First-phase ejection fraction: association with remodelling and outcome in aortic valve stenosis

Open Heart ◽

10.1136/openhrt-2020-001543 ◽

2021 ◽

Vol 8 (1) ◽

pp. e001543

Author(s):

Rasmus Carter-Storch ◽

Nils Sofus Borg Mortensen ◽

Nicolaj Lyhne Christensen ◽

Mulham Ali ◽

Kristian Bach Laursen ◽

...

Keyword(s):

Aortic Valve ◽

Ejection Fraction ◽

Primary Endpoint ◽

Global Longitudinal Strain ◽

Wall Stress ◽

Dependent Measure ◽

Left Ventricular ◽

Aortic Valve Area ◽

Link Type ◽

Asymptomatic Patients

BackgroundFirst-phase ejection fraction (EF1), the left ventricular (LV) ejection fraction (EF) until the time of peak transaortic velocity, is a novel marker of subclinical LV dysfunction able to predict adverse events in aortic stenosis (AS). This study investigated the association between end-systolic wall stress (ESWS) and EF1 in severe AS, as well as the prognostic value of EF1 in severe asymptomatic AS.MethodsTwo prospectively gathered cohorts of 94 asymptomatic patients and 108 symptomatic patients scheduled for aortic valve replacement (AVR), all with severe AS (aortic valve area <1 cm2) were stratified according to the median value of EF1 (33%). EF1 was defined as the EF at peak transaortic velocity. Asymptomatic patients were followed up for 3 years for the combined end-point of death, AVR or admission with heart failure.ResultsEF1 correlated with EF and was inversely associated with ESWS. In multivariate regression analysis, ESWS (p<0.001) and replacement fibrosis measured by MRI (p=0.02) were associated with EF1. Among asymptomatic patients, EF1 above the median was associated with the combined primary endpoint (HR=0.53 (95% CI 0.33 to 0.87)), while global longitudinal strain and EF were not. Among 42 patients with discordant AS (mean gradient <40 mm Hg), EF1 above median was associated with the primary endpoint (HR 0.28 (95% CI 0.12 to 0.61)).ConclusionEF1 is an afterload-dependent measure that is associated with events in patients with asymptomatic severe AS. The afterload dependency of EF1 may be useful in timing of risk stratification in patients with discordant AS.Trial registration numbersNCT02395107 and NCT02316587.

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P3696Correlates of the ratio of acceleration time to ejection time in patients with aortic stenosis: an echocardiographic and computed tomography study

European Heart Journal ◽

10.1093/eurheartj/ehz745.0550 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

A Altes ◽

M Sochala ◽

D Attias ◽

J Dreyfus ◽

M Toledano ◽

...

Keyword(s):

Computed Tomography ◽

Aortic Valve ◽

Aortic Stenosis ◽

Peak Velocity ◽

Left Ventricular ◽

Volume Index ◽

Multivariate Linear Regression Analysis ◽

Aortic Valve Area ◽

Ejection Time ◽

Acceleration Time

Abstract Background Acceleration time to ejection time ratio (AT/ET) prolongation is associated with increased mortality in patients with aortic stenosis (AS). Purpose To identify the determinants associated with increased AT/ET. Methods The relationships between AT/ET ratio, clinical and Doppler echocardiographic variables of interest in the setting of AS were studied in 1107 patients with AS and preserved left ventricular (LV) ejection fraction (EF), with Computed Tomography – Aortic Valve Calcium (CT-AVC) score studied in a subgroup of 342 patients. Results In univariate analysis, AT/ET ratio did correlate with aortic peak velocity (Vmax, r=0.57, p<0.0001), mean pressure gradient (MPG, r=0.60, p<0.0001), aortic valve area (AVA, r=−0.50, p<0.0001) and CT-AVC score (r=0.24, p<0.0001). An AT/ET ratio had a good accuracy to predict an aortic peak velocity ≥4 m/s, a MPG≥40 mmHg, or an AVA≤1.0 cm2, with an optimal cut-off value of 0.34. By multivariate linear regression analysis, presence of AS-related symptoms, decreased LV stroke volume index, LVEF, systolic blood pressure (SBP), absence of diabetes mellitus, and increased LV mass index, relative wall thickness, and Vmax were independently associated with increased AT/ET ratio (all P<0.05). In the subgroup of patients who underwent CT-AVC, CT-AVC score was independently associated with increased AT/ET ratio (P<0.05). Conclusion AT/ET ratio is related to echocardiographic and CT-AVC indices of AS severity. However, multiple intricate factors beyond hemodynamic and anatomic severity of AS influence AT/ET ratio including LV geometry, function and SBP. These findings should be considered when assessing AT/ET in patients with AS and preserved LVEF. Acknowledgement/Funding Local funding

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Atrial fibrillation is not an independent predictor of outcome in patients with aortic stenosis

Heart ◽

10.1136/heartjnl-2019-314996 ◽

2019 ◽

Vol 106 (4) ◽

pp. 280-286 ◽

Cited By ~ 3

Author(s):

Hongju Zhang ◽

Edward A El-Am ◽

Jeremy J Thaden ◽

Sorin V Pislaru ◽

Christopher G Scott ◽

...

Keyword(s):

Atrial Fibrillation ◽

Aortic Valve ◽

Aortic Stenosis ◽

Prognostic Significance ◽

Left Ventricular ◽

Volume Index ◽

Left Ventricular Ejection ◽

Aortic Valve Area ◽

Ventricular Ejection Fraction ◽

Cardiac Symptoms

ObjectivesTo examine the prognostic significance of atrial fibrillation (AF) versus sinus rhythm (SR) on the management and outcomes of patients with severe aortic stenosis (AS).Methods1847 consecutive patients with severe AS (aortic valve area ≤1.0 cm2 and aortic valve systolic mean Doppler gradient ≥40 mm Hg or peak velocity ≥4 m/s) and left ventricular ejection fraction ≥50% were identified. The independent association of AF and all-cause mortality was assessed.ResultsAge was 76±11 years and 46% were female; 293 (16%) patients had AF and 1554 (84%) had SR. In AF, 72% were symptomatic versus 71% in SR. Survival rate at 5 years for AF (41%) was lower than SR (65%) (age- and sex-adjusted HR=1.66 (1.40–1.98), p<0.0001). In multivariable analysis, factors associated with mortality included age (HR per 10 years=1.55 (1.42–1.69), p<0.0001), dyspnoea (HR=1.58 (1.33–1.87), p<0.0001), ≥ moderate mitral regurgitation (HR=1.63 (1.22–2.18), p=0.001), right ventricular systolic dysfunction (HR=1.88 (1.52–2.33), p<0.0001), left atrial volume index (HR per 10 mL/m2=1.13 (1.07–1.19), p<0.0001) and aortic valve replacement (AVR) (HR=0.44 (0.38–0.52), p<0.0001). AF was not a predictor of mortality independent of variables strongly correlated HR=1.02 (0.84–1.25), p=0.81). The 1-year probability of AVR following diagnosis of severe AS was lower in AF (49.8%) than SR (62.5%) (HR=0.73 (0.62–0.86), p<0.001); among patients with AF not referred for AVR, symptoms were frequently attributed to AF instead of AS.ConclusionAF was associated with poor prognosis in patients with severe AS, but apparent differences in outcomes compared with SR were explained by factors other than AF including concomitant cardiac abnormalities and deferral of AVR due to attribution of cardiac symptoms to AF.

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