scholarly journals Effect of the 2017 European Guidelines on Reclassification of Severe Aortic Stenosis and Its Influence on Management Decisions for Initially Asymptomatic Aortic Stenosis

2020 ◽  
Vol 13 (12) ◽  
Author(s):  
Daniel C.S. Chan ◽  
Anvesha Singh ◽  
John P. Greenwood ◽  
Dana K. Dawson ◽  
Chim C. Lang ◽  
...  
Keyword(s):  
Aortic Stenosis ◽  
Severe Aortic Stenosis ◽  
Calcium Score ◽  
Cardiovascular Death ◽  
End Point ◽  
Exercise Tolerance Testing ◽  
Asymptomatic Patients ◽  
Mean Pressure ◽  
European Society Of Cardiology ◽  
Tolerance Testing

Background: The 2017 European Society of Cardiology guidelines for valvular heart disease included changes in the definition of severe aortic stenosis (AS). We wanted to evaluate its influence on management decisions in asymptomatic patients with moderate-severe AS. Methods: We reclassified the AS severity of the participants of the PRIMID-AS study (Prognostic Importance of Microvascular Dysfunction in Asymptomatic Patients With AS), using the 2017 guidelines, determined their risk of reaching a clinical end point (valve replacement for symptoms, hospitalization, or cardiovascular death) and evaluated the prognostic value of aortic valve calcium score and biomarkers. Patients underwent echocardiography, cardiac magnetic resonance imaging, exercise tolerance testing, and biomarker assessment. Results: Of the 174 participants, 45% (56/124) classified as severe AS were reclassified as moderate AS. This reclassified group was similar to the original moderate group in clinical characteristics, gradients, calcium scores, and remodeling parameters. There were 47 primary end points (41 valve replacement, 1 death, and 5 hospitalizations—1 chest pain, 2 dyspnea, 1 heart failure, and 1 syncope) over 368±156 days follow-up. The severe and reclassified groups had a higher risk compared with moderate group (adjusted hazard ratio 4.95 [2.02–12.13] and 2.78 [1.07–7.22], respectively), with the reclassified group demonstrating an intermediate risk. A mean pressure gradient ≥31 mm Hg had a 7× higher risk of the primary end point in the reclassified group. Aortic valve calcium score was more prognostic in females and low valve area but not after adjusting for gradients. NT-proBNP (N-terminal pro-brain-type natriuretic peptide) and myocardial perfusion reserve were associated with the primary end point but not after adjusting for positive exercise tolerance testing. Troponin was associated with cardiovascular death or unplanned hospitalizations. Conclusions: Reclassification of asymptomatic severe AS into moderate AS was common using the European Society of Cardiology 2017 guidelines. This group had an intermediate risk of reaching the primary end point. Exercise testing, multimodality imaging, and lower mean pressure gradient threshold of 31 mm Hg may improve risk stratification. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01658345.

scholarly journals Use and success evaluation of percutaneous aortic balloon valvuloplasty in different hemodynamic entities of severe aortic stenosis in the TAVR era

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
K Piayda ◽  
A Wimmer ◽  
H Sievert ◽  
K Hellhammer ◽  
S Afzal ◽  
...  
Keyword(s):  
Heart Failure ◽  
Aortic Valve ◽  
Aortic Stenosis ◽  
Aortic Valve Replacement ◽  
Pressure Gradient ◽  
Severe Aortic Stenosis ◽  
Primary Treatment ◽  
Low Flow ◽  
Mean Pressure ◽  
The Mean

Abstract Background In the era of transcatheter aortic valve replacement (TAVR), there is renewed interest in percutaneous balloon aortic valvuloplasty (BAV), which may qualify as the primary treatment option of choice in special clinical situations. Success of BAV is commonly defined as a significant mean pressure gradient reduction after the procedure. Purpose To evaluate the correlation of the mean pressure gradient reduction and increase in the aortic valve area (AVA) in different flow and gradient patterns of severe aortic stenosis (AS). Methods Consecutive patients from 01/2010 to 03/2018 undergoing BAV were divided into normal-flow high-gradient (NFHG), low-flow low-gradient (LFLG) and paradoxical low-flow low-gradient (pLFLG) AS. Baseline characteristics, hemodynamic and clinical information were collected and compared. Additionally, the clinical pathway of patients (BAV as a stand-alone procedure or BAV as a bridge to aortic valve replacement) was followed-up. Results One-hundred-fifty-six patients were grouped into NFHG (n=68, 43.5%), LFLG (n=68, 43.5%) and pLFLG (n=20, 12.8%) AS. Underlying reasons for BAV and not TAVR/SAVR as the primary treatment option are displayed in Figure 1. Spearman correlation revealed that the mean pressure gradient reduction had a moderate correlation with the increase in the AVA in patients with NFHG AS (r: 0.529, p<0.001) but showed no association in patients with LFLG (r: 0.145, p=0.239) and pLFLG (r: 0.030, p=0.889) AS. Underlying reasons for patients to undergo BAV and not TAVR/SAVR varied between groups, however cardiogenic shock or refractory heart failure (overall 46.8%) were the most common ones. After the procedure, independent of the hemodynamic AS entity, patients showed a functional improvement, represented by substantially lower NYHA class levels (p<0.001), lower NT-pro BNP levels (p=0.003) and a numerical but non-significant improvement in other echocardiographic parameters like the left ventricular ejection fraction (p=0.163) and tricuspid annular plane systolic excursion (TAPSE, p=0.066). An unplanned cardiac re-admission due to heart failure was necessary in 23.7% patients. Less than half of the patients (44.2%) received BAV as a bridge to TAVR/SAVR (median time to bridge 64 days). Survival was significantly increased in patients having BAV as a staged procedure (log-rank p<0.001). Conclusion In daily clinical practice, the mean pressure gradient reduction might be an adequate surrogate of BAV success in patients with NFHG AS but is not suitable for patients with other hemodynamic entities of AS. In those patients, TTE should be directly performed in the catheter laboratory to correctly assess the increase of the AVA. BAV as a staged procedure in selected clinical scenarios increases survival and is a considerable option in all flow states of severe AS. (NCT04053192) Figure 1 Funding Acknowledgement Type of funding source: None

Abstract 15388: Persistent Pulmonary Hypertension After Transcatheter Aortic Valve Implantation: Impact on Mortality

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Maria Drakopoulou ◽  
Konstantinos Stathogiannis ◽  
Konstantinos Toutouzas ◽  
George Latsios ◽  
Andreas Synetos ◽  
...  
Keyword(s):  
Pulmonary Hypertension ◽  
Aortic Stenosis ◽  
Pulmonary Artery ◽  
Severe Aortic Stenosis ◽  
Systolic Pressure ◽  
Right Atrial ◽  
Pulmonary Artery Systolic Pressure ◽  
End Point ◽  
The Right ◽  
The Impact

Objective: Severe aortic stenosis leads to increased pulmonary arterial systolic pressure. A controversy still remains regarding the impact of persistent pulmonary hypertension (PHT) on prognosis of patients undergoing transcatheter aortic valve implantation (TAVI). We sought to investigate the impact of persistent PHT on 2-year all-cause mortality of patients with severe aortic stenosis following TAVI. Methods: Patients with severe and symptomatic aortic stenosis (effective orifice area [EOA]≤1 cm 2 ) who were scheduled for TAVI with a self-expanding valve at our institution were prospectively enrolled. Prospectively collected echocardiographic data before and after TAVI were retrospectively analyzed in all patients. Pulmonary artery systolic pressure was estimated as the sum of the right ventricular to the right atrial gradient during systole and the right atrial pressure. PHT following TAVI was classified as absent if <35 mmHg and persistent if ≥35 mmHg. Primary clinical end-point was 2-year all-cause mortality defined according to the criteria proposed by the Valve Academic Research Consortium-2. Results: Hundred and forty patients (mean age: 82±9 years) were included in the study. The primary clinical end point occurred in 17 patients (12%) during a median follow-up period of 2 years. Mean pulmonary artery systolic pressure was reduced in all patients following TAVI (45±9 versus 41±6 mmHg, p<0.01). Mortality rate was higher in patients with persistent PHT compared to patients with normal pulmonary artery systolic pressure following TAVI (26% versus 14 %, p<0.01). Patients that reached the primary clinical end point had a higher post procedural mean systolic pulmonary pressure (43±9 versus 39±6 mmHg, p=0.02). In multivariate regression analysis, persistence of PHT (OR: 2.51, 95% CI: 1.109-7.224, p=0.01) was an independent predictor of long-term mortality. Conclusions: The persistence of pulmonary hypertension after TAVI is associated with long term mortality. Identifying the population that will clearly benefit from TAVI is still need to be validated by larger trials.

scholarly journals Timing of Intervention in Asymptomatic Patients with Aortic Stenosis

2021 ◽  
Vol 16 ◽  
Author(s):  
Teresa Sevilla ◽  
Ana Revilla-Orodea ◽  
J Alberto San Román
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Aortic Valve Replacement ◽  
Valve Replacement ◽  
Severe Aortic Stenosis ◽  
Perioperative Complications ◽  
Scientific Evidence ◽  
Optimal Timing ◽  
Common Disease ◽  
Asymptomatic Patients

Aortic stenosis is a very common disease. Current guidelines recommend intervention mainly in symptomatic patients; aortic valve replacement can be considered in asymptomatic patients under specific conditions, but the evidence supporting these indications is poor. Continuous advances in both surgical and percutaneous techniques have substantially decreased rates of perioperative complications and mortality; with this in mind, many authors suggest that earlier intervention in patients with severe aortic stenosis, when they are still asymptomatic, may be indicated. This paper summarises what is known about the natural history of severe aortic stenosis and the scientific evidence available about the optimal timing for aortic valve replacement.

Abstract 11653: The Qualitative Grading of Aortic Valve Calcification in Severe Aortic Stenosis is Weakly Associated With Aortic Valve Weight and is Gender Dependent

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Dragos Alexandru ◽  
Florentina Petillo ◽  
Simcha Pollack ◽  
Nathaniel Reichek ◽  
Eddy Barasch
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Severe Aortic Stenosis ◽  
Pearson Correlation ◽  
Calcium Score ◽  
Aortic Valve Calcification ◽  
Test Analysis ◽  
Valve Calcification ◽  
Exact Test ◽  
The Difference

Background: In severe aortic stenosis (AS), qualitative estimation of aortic valve calcification (AVC) burden by echocardiography has diagnostic and prognostic value. Hypothesis: there is a weak association between a qualitative calcium score (QCS) by TEE and AV weight in severe AS. Methods: Between 2010-2014, of 719 pts who underwent surgical AVR for isolated severe AS, QCS was feasible in 483 (67%): mean age 76.7 ± 9.5 yrs, 59% males, EF 56 ±12%, AVAi 0.35 ±0.09 cm2/m2, AVW 2.45 ± 0.09 g, QCS 3.5± 0.57, 11% bicuspid valves . AVC was determined using short- and long-axis views and graded as mild (1) localized, small, nondense calcifications to severe (4) extensive thickening and calcification of all cusps. TEEs were done on the day of surgery and excised valves were weighed. Independent t-test, Fisher’s exact test, analysis of variance, and Pearson correlation were done as appropriate. Results: Intraclass correlations for intra and interobserver variability were 0.76 and 0.53 , respectively.The association between indices of AS severity and AVC burden, is stronger for AVW than for QCS (table).19 pts had QCS = 2, 183 = 3 and 280 = 4. A QCS of 2 to 4 corresponded to an AVW of 1 to 6 g. The correlation between QCS and AVW was 0.11, p=.01, and 0.09, p =.04 when controlling for age, sex and BSA. QCS-AVW association was gender dependent : for females (196), who had a lower severity of stenosis, r=0.23, p=0.001, for males (286), r=0.02, p=.68 with p =.02 for the difference. Conclusions: 1. In severe AS, QCS by TEE has limited reliability with no relationship with AVW in males and a weak one in females. 2. The utilization of QCS in severe AS even when employing TEE is weakly associated with total AVC burden and should probably be replaced by quantitative objective non- echocardiographic methods.

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