Impact of Atrial Fibrillation on the Symptoms and Echocardiographic Evaluation of Patients With Aortic Stenosis

Heart Failure With Preserved Ejection Fraction Phenotype Is Associated With Early Symptom Onset in Aortic Stenosis and Residual Symptoms After Transcatheter Aortic Valve Implantation

BACKGROUND

Aortic stenosis can lead to cardiac adaptations and symptoms similar to heart failure with preserved ejection fraction. We hypothesized that a heart failure with preserved ejection fraction phenotype in aortic stenosis is associated with earlier onset of symptoms and reduced symptomatic response after transcatheter aortic valve implantation (TAVI).

METHODS AND RESULTS

This retrospective cohort study included 469 patients with moderate aortic stenosis. We determined heavy, hypertension, atrial fibrillation, pulmonary, elder, filling pressure (H2FPEF) score at diagnosis and compared aortic peak jet velocity at onset of dyspnea in patients with low (<6) and high (≥6) H2FPEF score. In a separate cohort of 601 patients undergoing TAVI, we compared New York Heart Association class, NT-proBNP (N-terminal pro-B-type natriuretic peptide), and cardiovascular mortality post-TAVI between patients with low and high H2FPEF scores. In patients with aortic stenosis and a high H2FPEF score (n=43, 9.2%), the median peak jet velocity at onset of dyspnea was 4.2 versus 4.4 m/s in patients with a low H2FPEF score (P<0.001). After TAVI, a high H2FPEF score (n=123, 20%) was associated with a lower proportion of New York Heart Association class I at 30 days (49% versus 61%; P=0.04), persistently elevated NT-proBNP, and higher 5-year rate of cardiovascular mortality (36% versus 30%; P=0.012), compared with a low H2FPEF score.

CONCLUSIONS

Patients with aortic stenosis with a heart failure with preserved ejection fraction phenotype are more likely to develop symptoms at lower gradients and have worse outcomes post-TAVI. Randomized trials are warranted to investigate whether medical therapy targeted at heart failure with preserved ejection fraction delays onset of symptoms and improves symptomatic response after TAVI.

Echocardiographic assessment of atrial, ventricular, and valvular function in patients with atrial fibrillation-an expert proposal by the german working group of cardiovascular ultrasound

Echocardiography in patients with atrial fibrillation is challenging due to the varying heart rate. Thus, the topic of this expert proposal focuses on an obvious gap in the current recommendations about diagnosis and treatment of atrial fibrillation (AF)-the peculiarities and difficulties of echocardiographic imaging. The assessment of systolic and diastolic function-especially in combination with valvular heart diseases-by echocardiography can basically be done by averaging the results of echocardiographic measurements of the respective parameters or by the index beat approach, which uses a representative cardiac cycle for measurement. Therefore, a distinction must be made between the functionally relevant status, which is characterized by the averaging method, and the best possible hemodynamic status, which is achieved with the most optimal left ventricular (LV) filling according to the index beat method with longer previous RR intervals. This proposal focuses on left atrial and left ventricular function and deliberately excludes problems of echocardiography when assessing left atrial appendage in terms of its complexity. Echocardiography of the left atrial appendage is therefore reserved for its own expert proposal.

Aortic Valve Calcium Score: Applications in Clinical Practice and Scientific Research-A Narrative Review

In this narrative review, we investigate the essential role played by the computed tomography Aortic Valve Calcium Score (AVCS) in the cardiovascular diagnostic landscape, with a special focus on its implications for clinical practice and scientific research. Calcific aortic valve stenosis is the most prevalent type of aortic stenosis (AS) in industrialized countries, and due to the aging population, its prevalence is increasing. While transthoracic echocardiography (TTE) remains the gold standard, AVCS stands out as an essential complementary tool in evaluating patients with AS. The advantage of AVCS is its independence from flow; this allows for a more precise evaluation of patients with discordant findings in TTE. Further clinical applications of AVCS include in the assessment of patients before transcatheter aortic valve replacement (TAVR), as it helps in predicting outcomes and provides prognostic information post-TAVR. Additionally, we describe different AVCS thresholds regarding gender and the anatomical variations of the aortic valve. Finally, we discuss various scientific studies where AVCS was applied. As AVCS has some limitations, due to the pathophysiologies of AS extending beyond calcification and gender differences, scientists strive to validate contrast-enhanced AVCS. Furthermore, research on developing radiation-free methods of measuring calcium content is ongoing.