Abstract 18460: Asymmetric Septal Hypertrophy as a Prognostic Indicator During Progression of Aortic Valve Stenosis

Objective: Asymmetric septal hypertrophy (ASH) in patients with severe aortic stenosis (AS) has been associated with increased perioperative morbidity and mortality in smaller studies with severe aortic stenosis (AS). This association has not been tested in a large, longitudinal study. Methods: Clinical, echocardiographic and outcome data from 1730 patients with asymptomatic AS, participated in the Simvastatin Ezetimibe in Aortic Stenosis study (SEAS), a randomized placebo controlled study evaluating the effect of lipid lowering medications on progression of AS, were used. ASH was considered present if interventricular septal/posterior wall thickness ratio exceeded 1.5. The association of ASH with rate of major cardiovascular (CV) events was tested in time-dependent cox-regression analysis. Results: During a median of 4.3 years follow-up, ASH developed in 17.0 % of patients, and was associated with higher left ventricular mass (LVM) and body mass index (BMI) compared to non-ASH patients (all p<0.05). In time-varying Cox regression analysis, ASH predicted a 50% greater incidence of ischemic CV events (ICE), a 63% greater incidence in the need for coronary artery bypass grafting (CABG) at the time of aortic valve replacement, and a 2-fold higher incidence of hospitalization for heart failure due to progression of AS (CHFAS) independent of important confounders (all p<0.05) (Table). Conclusions: Development of ASH during progression of AS was a strong predictor of major CV events in patients participating in the SEAS-study. Table: Results are presented as Hazard ratio (95% Confidence Interval).

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Residual left ventricular hypertrophy with adverse clinical outcomes in patients with severe aortic stenosis and asymmetric septal hypertrophy after aortic valve replacement

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezy486 ◽

2019 ◽

Vol 56 (2) ◽

pp. 343-350

Author(s):

Haitao Xu ◽

Yabing Duan ◽

Xin Yuan ◽

Hengchao Wu ◽

Yunhu Song ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Aortic Valve Replacement ◽

Independent Predictor ◽

Severe Aortic Stenosis ◽

Left Ventricular ◽

Lv Mass ◽

Asymmetric Septal Hypertrophy ◽

Reverse Remodelling ◽

Septal Hypertrophy

Abstract OBJECTIVES The aim of this study is to describe the temporal pattern of left atrial (LA) and left ventricular (LV) reverse remodelling and to evaluate the impact of residual LV hypertrophy on the prognosis of patients with severe aortic stenosis and asymmetric septal hypertrophy undergoing aortic valve replacement (AVR). METHODS We retrospectively reviewed 59 consecutive patients who underwent AVR for severe aortic stenosis and asymmetric septal hypertrophy. They were divided into the normal LV mass group and the residual LV hypertrophy group according to the LV mass index (LVMI) 2 years after AVR. Thirty patients were eligible for analysis of the time-dependent changes in LA and LV reverse remodelling. RESULTS The interventricular septal thickness and LVMI gradually decreased and reached their lowest points 2 years after operation, whereas the LA dimension rapidly decreased in the early postoperative period and plateaued at 3 months. The multivariable analysis revealed a higher preoperative LVMI [odds ratio 6.36 (1.678–24.11); P = 0.007] as an independent predictor of residual hypertrophy 2 years after operation. The Cox proportional hazards model showed that a higher postoperative peak velocity [hazard ratio 6.715 (1.405–32.104); P = 0.017] was an independent predictor of long-term non-fatal cardiovascular hospitalization. Patients with residual hypertrophy 2 years after AVR had a higher rate of non-fatal cardiovascular hospitalization (P = 0.014). CONCLUSIONS For patients with severe aortic stenosis and asymmetric septal hypertrophy, maximum LA recovery occurred 3 months after AVR, whereas maximum LV recovery occurred 2 years thereafter. A higher preoperative LVMI may lead to postoperative residual hypertrophy, which is associated with adverse clinical outcomes.

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Abstract 19123: Elevated Growth and Differentiation Factor 15 (GDF15) Levels Predict Outcome in Patients With Severe Aortic Stenosis Undergoing Tavi

Circulation ◽

10.1161/circ.130.suppl_2.19123 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Nora Krau ◽

Sandra Freitag-Wolf ◽

Doreen Brehm ◽

Rainer Petzina ◽

Georg Lutter ◽

...

Keyword(s):

Regression Analysis ◽

Aortic Valve ◽

Risk Stratification ◽

Transforming Growth Factor ◽

Cox Regression ◽

Severe Aortic Stenosis ◽

Statistical Significance ◽

Cox Regression Analysis ◽

Negative Outcome

Background: GDF15 belongs to the transforming growth factor superfamily and has a significant role in regulating inflammatory and apoptotic pathways. GDF15 is an emerging biomarker for risk stratification in cardiovascular disease. Here we analyze its prognostic value in patients with severe symptomatic aortic valve stenosis undergoing transcatheter aortic valve implantation (TAVI). Methods and Results: We prospectively enrolled 217 patients undergoing TAVI (using Edwards Sapien XT prostheses) at our institution over a continuous period of 35 month (2/2011-12/2013). All patients were available for complete follow up. Clinical parameters were determined before the procedure, biomarkers (GDF15 & NTproBNP) were measured before, 3 and 7 days after TAVI. The primary endpoint was survival time, all available prognostic factors were studied by Cox regression analysis with backward selection based on the likelihood ratio criteria. At median follow-up of 349 d (Q1-Q3 106-660d), a total of n=66 deaths occurred. 30d mortality was 6.9%. Mean age was 81.8 years (± 6.0 y) and 55.8% were females. Mean log. Euroscore (ES) was 25.4% (± 17.2%). Median preprocedural GDF15 values were 2256 pg/ml (Q1-Q3 1585.5-3082.0). In univariate analyses, increased GDF15 levels (upper quartile compared to lower three quartiles) revealed a HR of 2.4 (CI 1.5-3.9, p<0.001) for adverse outcome. In addition, also log. ES (p= 0.001), log. ES II (p=0.018), STS-Score (p=0.019), NTproBNP (p=0.037) and atrial fibrillation (p=0.02) demonstrated statistical significance for negative outcome. A multivariate Cox regression analysis including these factors and postprocedural aortic regurgitation, demonstrated that elevated GDF15 had a HR of 2.104 (CI 1.3-3.5; p=0.003) for negative outcome in patients undergoing TAVI, while elevated NTproBNP had HR of 1.412 (CI 0.8-2.4; p=0.212). Moreover, this analysis also revealed the log. ES as an independent risk factor (HR of 2.211, CI 1.3-3.7; p= 0.002). Conclusion: Increased GDF15 levels are associated with a poor prognosis in patients undergoing TAVI. Furthermore, GDF15 showed to be superior to the established biomarker NTproBNP in risk stratification of patients undergoing TAVI providing additional prognostic information.

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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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Abstract 19365: The Novel Biomarker Osteopontin Predicts Adverse Outcome in Patients Undergoing Treatment of Severe Aortic Stenosis by TAVI

Circulation ◽

10.1161/circ.130.suppl_2.19365 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Matthias Lutz ◽

Nora Ingersleben ◽

Mark Rosenberg ◽

Sandra Freitag-Wolf ◽

Doreen Brehm ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Aortic Valve Stenosis ◽

Matrix Protein ◽

Adverse Outcome ◽

Severe Aortic Stenosis ◽

Left Ventricular ◽

Extracellular Matrix Protein ◽

Data Set ◽

Cox Regression Analysis

Background: Osteopontin (OPN) is an extracellular matrix protein that plays an integral role in myocardial remodeling and was previously shown as an important emerging biomarker in risk evaluation of cardiovascular disease. However, its prognostic value in patients with pressure overload of the left ventricular, caused by symptomatic severe aortic valve stenosis, undergoing transcatheter aortic valve implantation (TAVI) remains unclear. Methods: N=217 patients undergoing TAVI (using balloon-expandable Edwards Sapien XT prostheses) were included prospectively over a continuous period from Feb. 2011 until Dec. 2013. For all patients a complete clinical data set including biomarkers (OPN and NTproBNP), basic clinical assessment and echocardiography before and 7 days after TAVI was obtained. The primary endpoint was survival time. During median follow-up of 349d (Q1, Q3: 106-659.5d), a total of 66 deaths occurred, 30d mortality was 6.9%. Mean age was 81.8 years (± 6.03 y) and 55.8 % of the patients were female. Mean log. Euroscore was 25.4% (± 17.2%) and mean STS Score was 6.2% (± 3.8%). Results: Median preprocedurale OPN values were significantly elevated in patients with severe aortic valve stenosis compared to healthy controls (675 ng/ml, Q1,Q3: 488.5-990.5 ng/ml vs. 386 ng/ml, Q1, Q3: 324.5 - 458.0, p<0.001). Increased OPN levels before TAVI (upper quartile compared to lower three quartiles) revealed a HR of 2.151 (CI 1.31-3.531, p=0.002) for reduced survival. Multivariate Cox regression analysis including NTproBNP, postprocedural aortic regurgitation, atrial fibrillation, clinical risk scores and preprocedural left ventricular function (EF) demonstrates that OPN is even superior to NTproBNP and preprocedural EF in predicting adverse prognosis, showing a HR of 1.826 (CI 1.096-3.044, p=0.021). Conclusions: Elevated OPN levels predict adverse outcome in patients with severe aortic stenosis undergoing TAVI. OPN is superior to the established biomarker NTproBNP in risk stratification of patients undergoing TAVI.

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Modified Septal Myectomy Using a Curved Knife for Left Ventricular Septal Hypertrophy

The Heart Surgery Forum ◽

10.1532/hsf98.2014409 ◽

2014 ◽

Vol 17 (5) ◽

pp. 269

Author(s):

Shinya Takahashi ◽

Taiichi Takasaki ◽

Futoshi Tadehara ◽

Takahiro Taguchi ◽

Keijiro Katayama ◽

...

Keyword(s):

Blood Flow ◽

Chest Pain ◽

Aortic Valve ◽

Cross Section ◽

Left Ventricular ◽

Chest Discomfort ◽

Septal Myectomy ◽

Asymmetric Septal Hypertrophy ◽

Septal Hypertrophy ◽

Septal Myocardium

An 86-year-old woman presented with chest pain and discomfort. Echocardiography revealed severe aortic valve stenosis and asymmetric septal hypertrophy. Aortic valve replacement and myectomy were performed using a curved knife. The blade was U-shaped in cross-section, and was curved upward along the long axis. Hypertrophic septal myocardium was removed along the long axis of the left ventricle (LV), and a groove for blood flow was constructed. The patient was discharged uneventfully without recurrence of her chest discomfort. Our result suggested that a curved knife is a reasonable option for transaortic septal myectomy in patients with obstructive LV hypertrophy.

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Sex differences in transaortic flow rate and association with all-cause mortality in patients with severe aortic stenosis

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jeab045 ◽

2021 ◽

Author(s):

Sahrai Saeed ◽

Anastasia Vamvakidou ◽

Spyridon Zidros ◽

George Papasozomenos ◽

Vegard Lysne ◽

...

Keyword(s):

Sex Differences ◽

Aortic Stenosis ◽

Flow Rate ◽

Cox Regression ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Ventricular Ejection Fraction ◽

Cox Regression Analysis ◽

Increased Risk ◽

All Cause Mortality

Abstract Aims It is not known whether transaortic flow rate (FR) in aortic stenosis (AS) differs between men and women, and whether the commonly used cut-off of 200 mL/s is prognostic in females. We aimed to explore sex differences in the determinants of FR, and determine the best sex-specific cut-offs for prediction of all-cause mortality. Methods and results Between 2010 and 2017, a total of 1564 symptomatic patients (mean age 76 ± 13 years, 51% men) with severe AS were prospectively included. Mean follow-up was 35 ± 22 months. The prevalence of cardiovascular disease was significantly higher in men than women (63% vs. 42%, P < 0.001). Men had higher left ventricular mass and lower left ventricular ejection fraction compared to women (both P < 0.001). Men were more likely to undergo an aortic valve intervention (AVI) (54% vs. 45%, P = 0.001), while the death rates were similar (42.0% in men and 40.6% in women, P = 0.580). A total of 779 (49.8%) patients underwent an AVI in which 145 (18.6%) died. In a multivariate Cox regression analysis, each 10 mL/s decrease in FR was associated with a 7% increase in hazard ratio (HR) for all-cause mortality (HR 1.07; 95% CI 1.03–1.11, P < 0.001). The best cut-off value of FR for prediction of all-cause mortality was 179 mL/s in women and 209 mL/s in men. Conclusion Transaortic FR was lower in women than men. In the group undergoing AVI, lower FR was associated with increased risk of all-cause mortality, and the optimal cut-off for prediction of all-cause mortality was lower in women than men.

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

Open Heart ◽

10.1136/openhrt-2020-001443 ◽

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.

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Regression of left ventricular mass one year after aortic valve replacement for pure severe aortic stenosis

The American Journal of Cardiology ◽

10.1016/s0002-9149(01)02262-7 ◽

2002 ◽

Vol 89 (4) ◽

pp. 408-413 ◽

Cited By ~ 27

Author(s):

Harald P Kühl ◽

Andreas Franke ◽

David Puschmann ◽

Friedrich A Schöndube ◽

Rainer Hoffmann ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Aortic Valve Replacement ◽

Left Ventricular Mass ◽

Valve Replacement ◽

Severe Aortic Stenosis ◽

Left Ventricular ◽

Ventricular Mass ◽

One Year

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Left ventricular filling pressure and survival following aortic valve replacement for severe aortic stenosis

Heart ◽

10.1136/heartjnl-2019-315908 ◽

2020 ◽

Vol 106 (11) ◽

pp. 830-837 ◽

Cited By ~ 2

Author(s):

Jeremy J Thaden ◽

Mahesh Balakrishnan ◽

Jose Sanchez ◽

Rosalyn Adigun ◽

Vuyisile T Nkomo ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Aortic Valve Replacement ◽

Severe Aortic Stenosis ◽

Left Ventricular ◽

Filling Pressure ◽

Left Ventricular Filling ◽

Left Ventricular Filling Pressure ◽

Ventricular Filling Pressure ◽

Ventricular Filling

ObjectiveTo determine whether echocardiography-derived left ventricular filling pressure influences survival in patients with severe aortic stenosis (AS) undergoing aortic valve replacement (AVR).MethodsWe retrospectively reviewed 1383 consecutive patients with severe AS, normal ejection fraction and interpretable filling pressure undergoing AVR. Left ventricular filling pressure was determined according to current guidelines using mitral inflow, mitral annular tissue Doppler, estimated right ventricular systolic pressure and left atrial volume index. Cox proportional hazards regression was used to assess the influence of various parameters on mortality.ResultsAge was 75±10 years and 552 (40%) were female. Left ventricular filling pressure was normal in 325 (23%), indeterminate in 463 (33%) and increased in 595 (43%). Mean follow-up was 7.3±3.7 years, and mortality was 1.2%, 4.2% and 18.9% at 30 days and 1 and 5 years, respectively. Compared with patients with normal filling pressure, patients with increased filling pressure were older (78±9 vs 70±12, p<0.001), more often female (45% vs 35%, p=0.002) and were more likely to have New York Heart Association class III–IV symptoms (35% vs 24%, p=0.004), coronary artery disease (55% vs 42%, p<0.001) and concentric left ventricular hypertrophy (63% vs 37%, p<0.001). After correction for other factors, increased left ventricular filling pressure remained an independent predictor of mortality after successful AVR (adjusted HR 1.45 (95% CI 1.16 to 1.81), p=0.005).ConclusionsPreoperative increased left ventricular filling pressure is common in patients with AS undergoing AVR and has important prognostic implications, regardless of symptom status. Future prospective studies should consider whether patients with increased filling pressure would benefit from earlier operation.

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