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Richardson C, Gilbert T, Aslam S, Brookes CL, Singh A, Newby DE, Dweck MR, Stewart R, Myles PS, Briffa T, Selvanayagam J, Chow CK, Murphy GJ, Akowuah EF, Lord J, Barber S, Paola ASD, McCann GP, MBedBiol GSH. Rationale and design of the Early valve replacement in severe ASYmptomatic Aortic Stenosis Trial. Am Heart J 2024:S0002-8703(24)00128-5. [PMID: 38821453 DOI: 10.1016/j.ahj.2024.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 05/20/2024] [Accepted: 05/21/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Aortic valve replacement in asymptomatic severe aortic stenosis is controversial. The Early valve replacement in severe ASYmptomatic Aortic Stenosis (EASY-AS) trial aims to determine whether early aortic valve replacement improves clinical outcomes, quality of life and cost-effectiveness compared to a guideline recommended strategy of 'watchful waiting'. METHODS In a pragmatic international, open parallel group randomized controlled trial (NCT04204915), 2844 patients with severe aortic stenosis will be randomized 1:1 to either a strategy of early (surgical or transcatheter) aortic valve replacement or aortic valve replacement only if symptoms or impaired left ventricular function develop. Exclusion criteria include other severe valvular disease, planned cardiac surgery, ejection fraction <50%, previous aortic valve replacement or life expectancy <2 years. The primary outcome is a composite of cardiovascular mortality or heart failure hospitalization. The primary analysis will be undertaken when 663 primary events have accrued, providing 90% power to detect a reduction in the primary endpoint from 27.7% to 21.6% (hazard ratio 0.75). Secondary endpoints include disability-free survival, days alive and out of hospital, major adverse cardiovascular events and quality of life. RESULTS Recruitment commenced in March 2020 and is open in the UK, Australia, New Zealand and Serbia. Feasibility requirements were met in July 2022, and the main phase opened in October 2022, with additional international centers in set-up. CONCLUSIONS The EASY-AS trial will establish whether a strategy of early aortic valve replacement in asymptomatic patients with severe aortic stenosis reduces cardiovascular mortality or heart failure hospitalization and improves other important outcomes.
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Affiliation(s)
| | - Tom Gilbert
- University of Western Australia, Perth, Australia.
| | | | | | | | | | | | | | | | - Tom Briffa
- University of Western Australia, Perth, Australia
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2
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Martín M, Rozado J. Imaging in severe aortic stenosis: Looking at the future. Int J Cardiol 2024; 410:132183. [PMID: 38761977 DOI: 10.1016/j.ijcard.2024.132183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 05/14/2024] [Indexed: 05/20/2024]
Affiliation(s)
- María Martín
- Cardiology Department Hospital Universitario Central de Asturias. Oviedo Asturias, Spain.
| | - José Rozado
- Cardiology Department Hospital Universitario Central de Asturias. Oviedo Asturias, Spain
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Banovic M, Iung B, Putnik S, Mahendiran T, Vanderheyden M, Barbato E, Bartunek J. Asymptomatic Aortic Stenosis: From Risk Stratification to Treatment. Am J Cardiol 2024; 218:51-62. [PMID: 38432341 DOI: 10.1016/j.amjcard.2024.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 02/05/2024] [Accepted: 02/23/2024] [Indexed: 03/05/2024]
Abstract
Our understanding of the natural history of aortic stenosis has significantly increased over the last decade. There have been considerable advances in the diagnosis and risk stratification of patients with aortic stenosis and in surgical and anesthetic techniques. In addition, transcatheter aortic valve replacement has established itself as a viable alternative to surgical management. Inevitably, these developments have raised questions regarding the merits of waiting for symptom onset in asymptomatic patients with severe aortic stenosis before offering treatment. Recent observational and randomized trial data suggest that early intervention in asymptomatic patients with severe aortic stenosis and normal left ventricular function may confer a prognostic advantage to a watchful waiting strategy. In this review, we highlight advances in the management and risk stratification of patients with asymptomatic severe aortic stenosis with particular consideration of recent findings supporting early valvular intervention.
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Affiliation(s)
- Marko Banovic
- Cardiology Department, University Clinical Center of Serbia, Belgrade, Serbia; Belgrade Medical Faculty, University of Belgrade, Serbia.
| | - Bernard Iung
- Cardiology Department, Bichat Hospital APHP and Université Paris Cité, France
| | - Svetozar Putnik
- Belgrade Medical Faculty, University of Belgrade, Serbia; Cardiac-Surgery Department, University Clinical Center of Serbia, Belgrade, Serbia
| | - Thabo Mahendiran
- Cardiovascular Center, OLV Hospital, Aalst, Belgium; Cardiology Department, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Emanuele Barbato
- Cardiovascular Center, OLV Hospital, Aalst, Belgium; Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
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4
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Veselka J. Looking Back at 30 Years of Alcohol Septal Ablation and Looking Forward to the Future. Can J Cardiol 2024; 40:824-832. [PMID: 37774969 DOI: 10.1016/j.cjca.2023.09.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 08/31/2023] [Accepted: 09/22/2023] [Indexed: 10/01/2023] Open
Abstract
In the 30 years since Dr Sigwart's first pioneering procedures, alcohol septal ablation (ASA) has become the standard catheterisation procedure to reduce or eliminate obstruction in the left ventricular outflow tract. This procedure reduces the pressure gradient by 70%-80%, and only 10%-20% of patients have a residual gradient > 30 mm Hg after ASA. The mortality rate of the procedure is < 1%, and ∼ 10% of patients require permanent pacemaker implantation for higher degrees of atrioventricular block. Given the potential risks, ASA should be performed only in centres with extensive experience in the treatment of hypertrophic cardiomyopathy and with comprehensive therapeutic options, including myectomy. In the future, ASA is likely to be increasingly complemented by catheter-based mitral valve repair, which will increase its efficacy.
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Javadikasgari H, McGurk S, Newell PC, Awtry JA, Sabe AA, Kaneko T. Evolving Concept of Aortic Valve Replacement in Asymptomatic Patients With Severe Aortic Stenosis. Ann Thorac Surg 2024; 117:796-803. [PMID: 37660965 DOI: 10.1016/j.athoracsur.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 08/06/2023] [Accepted: 08/14/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Surgical treatment of asymptomatic severe aortic stenosis (AS) has been gaining attention ever since the results of the Early Surgery Versus Conventional Treatment in Very Severe Aortic Stenosis (RECOVERY) and Aortic Valve replacement versus conservative treatment in Asymptomatic seveRe aortic stenosis (AVATAR) trials showed survival benefits with early surgical aortic valve replacement (SAVR). This study analyzed the long-term clinical and echocardiographic outcomes of SAVR in asymptomatic severe AS. METHODS Between 2002 and 2020, 272 patients with asymptomatic severe AS and a left ventricular ejection fraction ≥50% underwent SAVR with or without concomitant aortic surgery and met the study criteria. The median follow-up was 8.5 years (interquartile range, 6-12.8 years), for a total of 2584 patient-years. The time course of the left ventricular mass index (LVMI) and the average E/E' (ratio of the Doppler-derived E wave to the tissue Doppler-derived E' wave) were assessed using 594 postoperative echocardiograms. The association of preoperative LVMI and average E/E' with survival was assessed using Cox proportional hazards. RESULTS There was no operative mortality. On longitudinal analyses, LVMI improved in patients who presented with moderate or severe preoperative left ventricular hypertrophy (LVH). However, after the early decline in average E/E', there was a late increase to greater than upper limit normal, particularly in patients with a preoperative average E/E'≥14. Postoperative survival was 100%, 94%, 84%, and 76% at 1, 5, 10, and 15 years, respectively, comparable to age- and sex-matched expected survival on the basis of the US general population. On adjusted Cox survival analysis, only moderate to severe LVH was associated with a survival penalty (hazard ratio], 2.32; 95% CI, 1.02-5.27; P = .045). CONCLUSIONS In asymptomatic patients with AS, SAVR restores survival and improves LVH, but patients with diastolic dysfunction are left with persistent dysfunction. Presentation with moderate or severe LVH at the time of surgery translated to a survival penalty. This observational study supports early SAVR in this population before development of LVH, although further investigation is needed.
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Affiliation(s)
- Hoda Javadikasgari
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Siobhan McGurk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Paige C Newell
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jake A Awtry
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ashraf A Sabe
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Tsuyoshi Kaneko
- Mary Culver Department of Surgery, Washington University School of Medicine, St Louis, Missouri
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6
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Généreux P, Schwartz A, Oldemeyer B, Cohen DJ, Redfors B, Prince H, Zhao Y, Lindman BR, Pibarot P, Leon MB. Design and rationale of the evaluation of transcatheter aortic valve replacement compared to surveillance for patients with asymptomatic severe aortic stenosis: The EARLY TAVR trial. Am Heart J 2024; 268:94-103. [PMID: 38056546 DOI: 10.1016/j.ahj.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND For patients with asymptomatic, severe aortic stenosis (AS) and preserved left ventricular ejection fraction, current guidelines recommend clinical surveillance every 6 to 12 months. To date, no randomized trials have examined whether an early intervention with transcatheter aortic valve replacement (TAVR) will improve outcomes among these patients. STUDY DESIGN AND OBJECTIVES EARLY TAVR is a prospective, randomized, controlled, and multicenter trial, with an event-based design. Asymptomatic severe AS patients (n = 900) are randomized 1:1 to either clinical surveillance or TAVR with the Edwards SAPIEN 3/SAPIEN 3 Ultra transcatheter heart valve. Patients are stratified by whether they are able to perform a treadmill stress test. The primary end point is death, stroke, or unplanned cardiovascular hospitalization. Patients who are asymptomatic but have a positive stress test will be followed in a registry and undergo aortic valve replacement as per current guidelines. CONCLUSIONS EARLY TAVR is the largest randomized trial to date assessing the role of early intervention among patients with asymptomatic severe AS compared to clinical surveillance and the first to study the role of TAVR. TRIAL REGISTRATION NUMBER NCT03042104.
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Affiliation(s)
- Philippe Généreux
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ.
| | - Allan Schwartz
- Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, NY
| | | | - David J Cohen
- Cardiovascular Research Foundation, New York, NY; St. Francis Hospital and Heart Center, Roslyn, NY
| | - Björn Redfors
- Cardiovascular Research Foundation, New York, NY; Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | | | | | | | - Philippe Pibarot
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Martin B Leon
- Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, NY; Cardiovascular Research Foundation, New York, NY
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7
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Magruder JT, Holst KA, Stewart J, Yadav PK, Thourani VH. Early Intervention in Asymptomatic Aortic Stenosis: What Are We Waiting For? Can J Cardiol 2024; 40:201-209. [PMID: 38036025 DOI: 10.1016/j.cjca.2023.11.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/06/2023] [Accepted: 11/25/2023] [Indexed: 12/02/2023] Open
Abstract
Aortic stenosis (AS) contributes to significant cardiovascular morbidity and mortality worldwide, and the natural history from symptoms to ventricular decompensation, heart failure, and death has been well documented. For more than 2 decades, technologies including imaging and biomarkers have shown a promising ability to detect myocardial damage associated with AS before symptoms arise. Current treatment guidelines rely heavily on symptoms or ventricular decompensation as triggers for aortic valve intervention. There is increasing appreciation of the relationship between myocardial damage due to AS before the emergence of symptoms, and a number of published randomised trials suggest a benefit to early intervention in asymptomatic AS, with additional trials actively enrolling. Future treatment paradigms may incorporate early detection of ventricular damage by noninvasive new technologies as triggers for asymptomatic intervention. Enthusiasm for early aortic valve replacement should be tempered by consideration of the competing risks of early valve intervention, but an increasing preponderance of evidence continues to suggest that earlier intervention in AS is warranted.
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Affiliation(s)
- J Trent Magruder
- Department of Cardiovascular Surgery, Piedmont Heart Institute, Athens, Georgia, USA
| | - Kimberly A Holst
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jim Stewart
- Department of Cardiology, Marcus Heart Valve Center, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Pradeep K Yadav
- Department of Cardiology, Marcus Heart Valve Center, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Heart Valve Center, Piedmont Heart Institute, Marcus Valve Center, Atlanta, Georgia, USA.
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Senguttuvan NB, Srinivasan NV, Panchanatham M, Abdulkader RS, Anandaram A, Polareddy DR, Ramesh S, Singh H, Yallanki H, Kaliyamoorthi D, Chidambaram S, Ramalingam V, Rajendran R, Muralidharan TR, Rao R, Seth A, Claessen B, Krishnamoorthy P. Systematic review and meta-analysis of early aortic valve replacement versus conservative therapy in patients with asymptomatic aortic valve stenosis with preserved left ventricle systolic function. Open Heart 2024; 11:e002511. [PMID: 38191233 PMCID: PMC10806528 DOI: 10.1136/openhrt-2023-002511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/14/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND A quarter of patients with severe aortic stenosis (AS) were asymptomatic, and only a third of them survived at the end of 4 years. Only a select subset of these patients was recommended for aortic valve replacement (AVR) by the current American College of Cardiology/American Heart Association guidelines. We intended to study the effect of early AVR (eAVR) in this subset of asymptomatic patients with preserved left ventricle function. METHODS AND RESULTS We searched PubMed and Embase for randomised and observational studies comparing the effect of eAVR versus conservative therapy in patients with severe, asymptomatic AS and normal left ventricular function. The primary outcome was all-cause mortality. The secondary outcomes were composite major adverse cardiac events (MACE) (study defined), myocardial infarction (MI), stroke, cardiac death, sudden death, the development of symptoms, heart failure hospitalisations and major bleeding. We used GRADEPro to assess the certainty of the evidence. In the randomised controlled trial (RCT) only analysis, we found no significant difference in all-cause mortality between the early aortic intervention group versus the conservative arm (CA) (incidence rate ratio, IRR (CI): 0.5 (0.2 to 1.1), I2=31%, p=0.09). However, in the overall cohort, we found mortality benefit for eAVR over CA (IRR (CI): 0.4 (0.3 to 0.7), I2=84%, p<0.01). There were significantly lower MACE, cardiac death, sudden death, development of symptoms and heart failure hospitalisations in the eAVR group. We noticed no difference in MI, stroke and major bleeding. CONCLUSION We conclude that there is no reduction in all-cause mortality in the eAVR arm in patients with asymptomatic AS with preserved ejection fraction. However, eAVR reduces heart failure related hospitalisations and death or heart failure hospitalisations. PROSPERO REGISTRATION NUMBER CRD42022306132.
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Affiliation(s)
| | | | - Manokar Panchanatham
- Department of Cardiology, SRIHER (Deemed to be University), Chennai, Tamil Nadu, India
| | | | - Asuwin Anandaram
- Department of Clinical Research, SRIHER (Deemed to be University), Chennai, Tamil Nadu, India
| | | | - Sankaran Ramesh
- Department of Cardiology, SRIHER (Deemed to be University), Chennai, Tamil Nadu, India
| | - Harsimran Singh
- Department of Cardiology, SRIHER (Deemed to be University), Chennai, Tamil Nadu, India
| | - Hanumath Yallanki
- Department of Medicine, SRIHER (Deemed to be University), Chennai, Tamil Nadu, India
| | | | | | - Vadivelu Ramalingam
- Department of Cardiology, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India
| | | | | | - Ravindar Rao
- Department of Cardiology, Rajasthan University of Health Sciences, Jaipur, Rajasthan, India
| | - Ashok Seth
- Department of Cardiology, Fortis Escorts Heart Institute and Research Centre, New Delhi, Delhi, India
| | - Bimmer Claessen
- Department of Cardiology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Parasuram Krishnamoorthy
- Cardiology, Icahn School of Medicine at Mount Sinai Zena and Michael A Wiener Cardiovascular Institute, New York, New York, USA
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9
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Schenker C, Wertli MM, Räber L, Haynes AG, Chiolero A, Rodondi N, Panczak R, Aujesky D. Regional variation and temporal trends in transcatheter and surgical aortic valve replacement in Switzerland: A population-based small area analysis. PLoS One 2024; 19:e0296055. [PMID: 38190381 PMCID: PMC10773935 DOI: 10.1371/journal.pone.0296055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 12/05/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND Aortic valve stenosis (AS) is the most common valvular heart disease and if severe, is treated with either transcatheter (TAVR) or surgical aortic valve replacement (SAVR). We assessed temporal trends and regional variation of these interventions in Switzerland and examined potential determinants of geographic variation. METHODS We conducted a population-based analysis using patient discharge data from all Swiss public and private acute care hospitals from 2013 to 2018. We generated hospital service areas (HSAs) based on patient flows for TAVR. We calculated age-standardized mean procedure rates and variation indices (extremal quotient [EQ] and systematic component of variation [SCV]). Using multilevel regression, we calculated the influence of calendar year and regional demographics, socioeconomic factors (language, insurance status), burden of disease, and number of cardiologists/cardiovascular surgeons on geographic variation. RESULTS Overall, 8074 TAVR and 11,825 SAVR procedures were performed in 8 HSAs from 2013 to 2018. Whereas the age-/sex-standardized rate of TAVR increased from 12 to 22 procedures/100,000 persons, the SAVR rate decreased from 33 to 24 procedures during this period. After full adjustment, the predicted TAVR and SAVR rates varied from 12 to 22 and 20 to 35 per 100,000 persons across HSAs, respectively. The regional procedure variation was low to moderate over time, with a low overall variation in TAVR (EQ 1.9, SCV 3.9) and SAVR (EQ 1.6, SCV 2.2). In multilevel regression, TAVR rates increased annually by 10% and SAVR rates decreased by 5%. Determinants of higher TAVR rates were older age, male sex, living in a German speaking area, and higher burden of disease. A higher proportion of (semi)private insurance was also associated with higher TAVR and lower SAVR rates. After full adjustment, 10.6% of the variance in TAVR and 18.4% of the variance in SAVR remained unexplained. Most variance in TAVR and SAVR rates was explained by language region and insurance status. CONCLUSION The geographic variation in TAVR and SAVR rates was low to moderate across Swiss regions and largely explained by differences in regional demographics and socioeconomic factors. The use of TAVR increased at the expense of SAVR over time.
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Affiliation(s)
- Carla Schenker
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maria M. Wertli
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Internal Medicine, Cantonal Hospital Baden, Baden, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Inselspital, Bern Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Arnaud Chiolero
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- School of Population and Global Health, McGill University, Montreal, Canada
- Population Health Laboratory (#PopHealthLab), University of Fribourg, Fribourg, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Radoslaw Panczak
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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10
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Takeji Y, Taniguchi T, Morimoto T, Shirai S, Kitai T, Tabata H, Kitano K, Ohno N, Murai R, Osakada K, Murata K, Nakai M, Tsuneyoshi H, Tada T, Amano M, Watanabe S, Shiomi H, Watanabe H, Yoshikawa Y, Nishikawa R, Yamamoto K, Obayashi Y, Toyofuku M, Tatsushima S, Kanamori N, Miyake M, Nakayama H, Nagao K, Izuhara M, Nakatsuma K, Inoko M, Fujita T, Kimura M, Ishii M, Usami S, Sawada K, Nakazeki F, Okabayashi M, Shirotani M, Inuzuka Y, Ando K, Komiya T, Minatoya K, Kimura T. In-hospital outcomes after SAVR or TAVI in patients with severe aortic stenosis. Cardiovasc Interv Ther 2024; 39:65-73. [PMID: 37349628 PMCID: PMC10764526 DOI: 10.1007/s12928-023-00942-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 06/06/2023] [Indexed: 06/24/2023]
Abstract
There were no data comparing the in-hospital outcomes after transcatheter aortic valve implantation (TAVI) with those after surgical aortic valve replacement (SAVR) in Japan. Among consecutive patients with severe AS between April 2018 and December 2020 in the CURRENT AS Registry-2, we identified 1714 patients who underwent aortic valve replacement (TAVI group: 1134 patients, and SAVR group: 580 patients). Patients in the TAVI group were much older (84.4 versus 73.6 years, P < 0.001) and more often had comorbidities than those in the SAVR group. In-hospital death rate was numerically lower in the TAVI group than in the SAVR group (0.6% versus 2.2%). After excluding patients with dialysis, in-hospital death rate was very low and comparable in the TAVI and SAVR groups (0.6% versus 0.8%). The rates of major bleeding and new-onset atrial fibrillation during index hospitalization were higher after SAVR than after TAVI (72% versus 20%, and 26% versus 4.6%, respectively), while the rate of pacemaker implantation was higher after TAVI than after SAVR (8.1% versus 2.4%). Regarding the echocardiographic data at discharge, the prevalence of patient-prosthesis mismatch was lower in the TAVI group than in the SAVR group (moderate: 9.0% versus 26%, and severe: 2.6% versus 4.8%). In this real-world data in Japan, TAVI compared with SAVR was chosen in much older patients with more comorbidities with severe AS. In-hospital death rate was numerically lower in the TAVI group than in the SAVR group.
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Affiliation(s)
- Yasuaki Takeji
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Shinichi Shirai
- Division of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Takeshi Kitai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroyuki Tabata
- Division of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Kazuki Kitano
- Division of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Nobuhisa Ohno
- Division of Cardiovascular Surgery, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Ryosuke Murai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Kohei Osakada
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Koichiro Murata
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Masanao Nakai
- Department of Cardiovascular Surgery, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Hiroshi Tsuneyoshi
- Department of Cardiovascular Surgery, Shizuoka General Hospital, Shizuoka, Japan
| | - Tomohisa Tada
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Masashi Amano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Shin Watanabe
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hirotoshi Watanabe
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yusuke Yoshikawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ryusuke Nishikawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ko Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yuki Obayashi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Shojiro Tatsushima
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Norio Kanamori
- Division of Cardiology, Shimada General Medical Center, Shimada, Japan
| | - Makoto Miyake
- Department of Cardiology, Tenri Hospital, Tenri, Japan
| | - Hiroyuki Nakayama
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Kazuya Nagao
- Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Masayasu Izuhara
- Department of Cardiology, Kishiwada City Hospital, Kishiwada, Japan
| | - Kenji Nakatsuma
- Department of Cardiology, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Moriaki Inoko
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Takanari Fujita
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Masahiro Kimura
- Department of Cardiology, Koto Memorial Hospital, Higashiomi, Japan
| | - Mitsuru Ishii
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Shunsuke Usami
- Department of Cardiology, Kansai Electric Power Hospital, Osaka, Japan
| | - Kenichiro Sawada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Fumiko Nakazeki
- Department of Cardiology, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Marie Okabayashi
- Department of Cardiology, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Manabu Shirotani
- Division of Cardiology, Faculty of Medicine, Nara Hospital, Kinki University, Ikoma, Japan
| | - Yasutaka Inuzuka
- Department of Cardiology, Shiga General Hospital, Moriyama, Japan
| | - Kenji Ando
- Division of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
- Department of Cardiology, Hirakata Kohsai Hospital, 1-2-1 Fujisaka Higashi-machi, Hirakata, 573-0153, Japan.
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11
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Taniguchi T, Morimoto T, Yamaji K, Shirai S, Ando K, Shiomi H, Takeji Y, Ohno N, Kanamori N, Yamazaki F, Koyama T, Kim K, Ehara N, Furukawa Y, Komiya T, Iwakura A, Shirotani M, Esaki J, Sakaguchi G, Fujii K, Nakayama S, Mabuchi H, Tsuneyoshi H, Eizawa H, Shiraga K, Hanyu M, Nakano A, Ishii K, Tamura N, Higashitani N, Kouchi I, Yamada T, Nishizawa J, Jinnai T, Morikami Y, Minatoya K, Kimura T. Life Expectancy of Patients With Severe Aortic Stenosis in Relation to Age and Surgical Risk Score. Ann Thorac Surg 2023; 116:1195-1203. [PMID: 36739072 DOI: 10.1016/j.athoracsur.2023.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 12/28/2022] [Accepted: 01/14/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND There is a paucity of data regarding shorter life expectancy after aortic valve replacement (AVR) in patients with severe aortic stenosis (AS). METHODS Among 3815 patients with severe AS enrolled in the CURRENT AS (Contemporary outcomes after sURgery and medical tREatmeNT in patients with severe Aortic Stenosis) registry, there were 1469 patients (initial AVR: n = 647; conservative strategy: n = 822) with low surgical risk, 1642 patients (initial AVR: n = 433; conservative strategy: n = 1209) with intermediate surgical risk, and 704 patients (initial AVR: n = 117; conservative strategy: n = 587) with high surgical risk. Among 1163 patients who actually underwent surgical AVR as the initial strategy, patients were divided into 4 groups according to age <65 years (n = 185), 65 to 74 (n = 394), 75 to 80 (n = 345), and >80 (n = 239). The expected survival of the general Japanese population was obtained from the Statistics Bureau of Japan. The surgical risk was estimated using The Society of Thoracic Surgery (STS) score. RESULTS The median follow-up was 3.7 years. The cumulative incidences of all-cause death were significantly lower in the initial AVR strategy than in the initial conservative strategy across the 3 STS groups. Shorter life expectancy after surgical AVR was seen especially in younger patients. The observed mortality in low-risk patients was comparable to the expected mortality across all the age-groups, while intermediate-risk patients aged <75 years, and high-risk patients across all age-groups had higher mortality compared with the expected mortality. CONCLUSIONS The risk stratification according to age and STS score might be useful to estimate shorter life expectancy after AVR, and these findings have implications for decision making in the choice of surgical or transcatheter AVR.
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Affiliation(s)
- Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Hyogo, Japan
| | - Kyohei Yamaji
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shinichi Shirai
- Department of Cardiovascular Medicine, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Kenji Ando
- Department of Cardiovascular Medicine, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yasuaki Takeji
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Nobuhisa Ohno
- Department of Cardiovascular Surgery, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Norio Kanamori
- Department of Cardiovascular Medicine, Shimada General Medical Center, Shimada, Japan
| | - Fumio Yamazaki
- Department of Cardiovascular Surgery, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Tadaaki Koyama
- Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Natsuhiko Ehara
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Atsushi Iwakura
- Department of Cardiovascular Surgery, Tenri Hospital, Tenri City, Japan
| | - Manabu Shirotani
- Department of Cardiovascular Medicine, Kindai University Nara Hospital, Nara, Japan
| | - Jiro Esaki
- Department of Cardiovascular Surgery, Mitsubishi Kyoto Hospital, West Kyoto, Japan
| | - Genichi Sakaguchi
- Department of Cardiovascular Surgery, Kindai University Hospital, Osaka Sayama City, Japan
| | - Kosuke Fujii
- Department of Cardiovascular Surgery, Kishiwada City Hospital, Kishiwada, Japan
| | - Shogo Nakayama
- Department of Cardiovascular Surgery, Osaka Red Cross Hospital, Osaka, Japan
| | - Hiroshi Mabuchi
- Department of Cardiovascular Medicine, Koto Memorial Hospital, Higashiomi, Japan
| | - Hiroshi Tsuneyoshi
- Department of Cardiovascular Surgery, Shizuoka General Hospital, Shizuoka, Japan
| | - Hiroshi Eizawa
- Department of Cardiovascular Medicine, Kobe City Nishi-Kobe Medical Center, Kobe, Japan
| | - Kotaro Shiraga
- Department of Cardiovascular Surgery, Kyoto Medical Center, Kyoto Japan
| | - Michiya Hanyu
- Department of Cardiovascular Surgery, Kitano Hospital, Osaka, Japan
| | - Akira Nakano
- Department of Cardiovascular Medicine, Hikone Municipal Hospital, Hikone, Japan
| | - Katsuhisa Ishii
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital, Fukushima, Japan
| | - Nobushige Tamura
- Department of Cardiovascular Surgery, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
| | - Nobuya Higashitani
- Department of Cardiovascular Medicine, Otsu Red Cross Hospital, Otsu, Japan
| | - Ichiro Kouchi
- Department of Cardiovascular Medicine, Saiseikai Noe Hospital, Osaka, Japan
| | - Tomoyuki Yamada
- Department of Cardiovascular Surgery, Shiga General Hospital, Shiga, Japan
| | - Junichiro Nishizawa
- Department of Cardiovascular Surgery, Hamamatsu Rosai Hospital, Hamamatsu City, Japan
| | - Toshikazu Jinnai
- Department of Cardiovascular Medicine, Otsu Red Cross Hospital, Otsu, Japan
| | - Yuko Morikami
- Department of Cardiovascular Medicine, Hirakata Kohsai Hospital, Hirakata, Japan
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
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12
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Huded CP, Arnold SV, Cohen DJ, Manandhar P, Vemulapalli S, Saxon JT, Chhatriwalla AK, Kosinski A, Spertus JA. Outcomes of Transcatheter Aortic Valve Replacement in Asymptomatic or Minimally Symptomatic Aortic Stenosis. JACC Cardiovasc Interv 2023; 16:2631-2641. [PMID: 37737793 DOI: 10.1016/j.jcin.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/26/2023] [Accepted: 07/11/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Little is known about the outcomes of transcatheter aortic valve replacement (TAVR) in minimally symptomatic patients. OBJECTIVES The authors aimed to evaluate the outcomes of patients with minimally symptomatic severe aortic stenosis treated with TAVR in the STS/ACC TVT registry. METHODS Minimally symptomatic status was defined as a baseline Kansas City Cardiomyopathy Questionnaire overall summary score (KCCQ-OS) ≥75. Clinical and health status outcomes of TAVR in patients with severe aortic stenosis and normal left ventricular ejection fraction were compared between minimally symptomatic patients and those with moderate or severe symptoms. RESULTS Among 231,285 patients who underwent TAVR between 2015 and 2021 (median age 80.0 years [IQR: 74.0-86.0 years], 47.5% female), 20.0% were minimally symptomatic before TAVR. Survival at 1 year was higher in minimally symptomatic patients vs those with moderate or severe symptoms (adjusted HR for death: 0.70 [95% CI: 0.66-0.75]). Mean KCCQ-OS increased by 2.7 points (95% CI: 2.6-2.9 points) at 30 days and 3.8 points (95% CI: 3.6-4.0 points) at 1 year in minimally symptomatic patients compared with increases of 32.2 points (95% CI: 32.0-32.3 points) at 30 days and 34.9 points (95% CI: 34.7-35.0 points) at 1 year in more symptomatic patients. Minimally symptomatic patients had higher odds of being alive and well at 1 year (OR: 1.19 [95% CI: 1.16-1.23]). CONCLUSIONS Although minimally symptomatic patients treated with TAVR experience only small improvements in health status, their overall outcomes are favorable with a higher likelihood of survival with good health status at 1 year compared with more symptomatic patients.
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Affiliation(s)
- Chetan P Huded
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri - Kansas City, Kansas City, Missouri, USA.
| | - Suzanne V Arnold
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri - Kansas City, Kansas City, Missouri, USA
| | - David J Cohen
- St. Francis Hospital and Heart Center, Roslyn, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | | | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Durham, North Carolina, USA; Duke University Medical Center, Durham, North Carolina, USA
| | - John T Saxon
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri - Kansas City, Kansas City, Missouri, USA
| | - Adnan K Chhatriwalla
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri - Kansas City, Kansas City, Missouri, USA
| | | | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri - Kansas City, Kansas City, Missouri, USA
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13
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Martín-Núñez E, Goñi-Olóriz M, Matilla L, Garaikoetxea M, Mourino-Alvarez L, Navarro A, Fernández-Celis A, Tamayo I, Gainza A, Álvarez V, Sádaba R, Barderas MG, Jover E, López-Andrés N. Influence of diabetes mellitus on the pathological profile of aortic stenosis: a sex-based approach. Cardiovasc Diabetol 2023; 22:280. [PMID: 37848892 PMCID: PMC10583330 DOI: 10.1186/s12933-023-02009-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/26/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND Diabetes mellitus (DM) accelerates the progression of aortic stenosis (AS), but how their underlying molecular mechanisms interact is not clear. Moreover, whether DM contributes to clinically relevant sex-differences in AS is unknown. In this work we aim to characterize the sex-specific profile of major pathological mechanisms fundamental to aortic valve (AV) degeneration in AS patients with or without concomitant DM. METHODS 283 patients with severe AS undergoing surgical valve replacement (27.6% DM, 59.4% men) were recruited. Expression of pathological markers related to AS were thoroughly assessed in AVs and valve interstitial cells (VICs) according to sex and presence of DM. Complementary in vitro experiments in VICs in the presence of high-glucose levels (25 mM) for 24, 48 and 72 h were performed. RESULTS Oxidative stress and metabolic dysfunction markers were increased in AVs from diabetic AS patients compared to non-diabetic patients in both sexes. However, disbalanced oxidative stress and enhanced inflammation were more predominant in AVs from male AS diabetic patients. Osteogenic markers were exclusively increased in the AVs of diabetic women. Basal characterization of VICs confirmed that oxidative stress, inflammation, calcification, and metabolic alteration profiles were increased in diabetic VICs with sex-specific differences. VICs cultured in hyperglycemic-like conditions triggered inflammatory responses in men, whereas in women rapid and higher production of pro-osteogenic molecules. CONCLUSIONS DM produces sex-specific pathological phenotypes in AV of AS patients. Importantly, women with diabetes are more prone to develop AV calcification. DM should be considered as a risk factor in AS especially in women.
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Affiliation(s)
- Ernesto Martín-Núñez
- Cardiovascular Translational Research, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), C/Irunlarrea 3, 31008, Pamplona, Spain
| | - Miriam Goñi-Olóriz
- Cardiovascular Translational Research, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), C/Irunlarrea 3, 31008, Pamplona, Spain
| | - Lara Matilla
- Cardiovascular Translational Research, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), C/Irunlarrea 3, 31008, Pamplona, Spain
| | - Mattie Garaikoetxea
- Cardiovascular Translational Research, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), C/Irunlarrea 3, 31008, Pamplona, Spain
| | - Laura Mourino-Alvarez
- Department of Vascular Physiopathology, Hospital Nacional de Parapléjicos, Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain
- Hospital Nacional de Paraplejicos, Servicio de Salud de Castilla-La Mancha (SESCAM), Toledo, Spain
| | - Adela Navarro
- Cardiovascular Translational Research, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), C/Irunlarrea 3, 31008, Pamplona, Spain
| | - Amaya Fernández-Celis
- Cardiovascular Translational Research, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), C/Irunlarrea 3, 31008, Pamplona, Spain
| | - Ibai Tamayo
- Research Methodology Unit, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Alicia Gainza
- Cardiovascular Translational Research, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), C/Irunlarrea 3, 31008, Pamplona, Spain
| | - Virginia Álvarez
- Cardiovascular Translational Research, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), C/Irunlarrea 3, 31008, Pamplona, Spain
| | - Rafael Sádaba
- Cardiovascular Translational Research, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), C/Irunlarrea 3, 31008, Pamplona, Spain
| | - María G Barderas
- Department of Vascular Physiopathology, Hospital Nacional de Parapléjicos, Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain
- Hospital Nacional de Paraplejicos, Servicio de Salud de Castilla-La Mancha (SESCAM), Toledo, Spain
| | - Eva Jover
- Cardiovascular Translational Research, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), C/Irunlarrea 3, 31008, Pamplona, Spain.
| | - Natalia López-Andrés
- Cardiovascular Translational Research, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), C/Irunlarrea 3, 31008, Pamplona, Spain.
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14
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Banovic M, Iung B, Wojakowski W, Van Mieghem N, Bartunek J. Asymptomatic Severe and Moderate Aortic Stenosis: Time for Appraisal of Treatment Indications. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2023; 7:100201. [PMID: 37745683 PMCID: PMC10512009 DOI: 10.1016/j.shj.2023.100201] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 04/11/2023] [Accepted: 04/13/2023] [Indexed: 09/26/2023]
Abstract
Over the last decades, we have witnessed considerable improvements in diagnostics and risk stratification of patients with significant aortic stenosis (AS), paralleled by advances in operative and anesthetic techniques. In addition, accumulating evidence points to the potential benefit of early valve replacement in such patients prior to the onset of symptoms. In parallel, interventional randomized trials have proven the benefit of transcatheter aortic valve replacement in comparison to a surgical approach to valve replacement over a broad risk spectrum in symptomatic patients with AS. This article reviews contemporary management approaches and scrutinizes open questions regarding timing and mode of intervention in asymptomatic patients with severe AS. We also discuss the challenges surrounding the management of symptomatic patients with moderate AS as well as emerging dilemmas related to the concept of a life-long treatment strategy for patients with AS.
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Affiliation(s)
- Marko Banovic
- Belgrade Medical Faculty, University of Belgrade, Belgrade, Serbia
- Cardiology Department, University Clinical Center of Serbia, Belgrade, Serbia
| | - Bernard Iung
- University of Paris, Paris, France
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris (AP-HP), Bichat Hospital, Paris, France
| | - Wojtek Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | | | - Jozef Bartunek
- Cardiovascular Center Aalst, OLV Hospital, Aalst, Belgium
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15
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Nahar N, Haque T, Kabiruzzaman M, Khan MAM, Choudhury SR, Malik FTN. Assessment of subclinical left ventricular systolic dysfunction in patients with asymptomatic severe aortic stenosis with preserved left ventricular systolic function by three-dimensional speckle tracking echocardiography. Echocardiography 2023; 40:952-957. [PMID: 37519280 DOI: 10.1111/echo.15662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 06/27/2023] [Accepted: 07/21/2023] [Indexed: 08/01/2023] Open
Abstract
OBJECTIVES Left ventricular dysfunction and remodeling can occur as a result of aortic valve stenosis (AS). Three-dimensional speckle tracking echocardiography (3D-STE) can detect early left ventricular myocardial dysfunction even before ejection fraction declines. The purpose of this study was to look at the relationship between various myocardial strain parameters measured by 3D-STE in asymptomatic severe AS patients from Bangladesh. METHODS This study included 46 patients with asymptomatic severe AS but preserved LV systolic function (mean age 50.11 ± 12.66 years, LVEF 63.78 ± 3.95%, AS group) and 33 healthy subjects with no cardiovascular disease (mean age 48.21 ± 4.53 years, LVEF 65.15 ± 3.13%, control group). 3D-STE was used to measure left ventricular global myocardial strain parameters such as peak systolic longitudinal strain (PSLS), circumferential strain, radial strain, and area strain. RESULTS The AS group had significantly thicker interventricular septum and posterior ventricular wall than the control group (1.49 ± .19 cm vs. .81 ± .09 cm, p < .001; 1.73 ± 1.71 cm vs. .81 ± .10 cm, p = .003, respectively.) In the AS group, the Indexed Aortic Valve Area (AVA) was significantly lower than in the control group. (.29 ± .10 vs. 2.03 ± .18, p < .001, respectively). In terms of LVEF (p = .102), left ventricular end diastolic volume (p = .075), or left ventricular end systolic volume (p = .092), no significant inter-group difference was found. However, global PSLS (-10.75 ± 2.27 vs. -16.42 ± 2.76, p < .001), circumferential strain (-14.26 ± 3.40 vs. -16.64 ± 2.56, p = .001), area strain (-22.70 ± 4.19 vs. -26.45 ± 9.90, p = .024) and radial strain (32.20 ± 8.77 vs. 41.00 ± 7.52, p < .001) in the AS group were significantly lower than in the control group. CONCLUSION Our findings showed reductions in left ventricular global myocardial strains, particularly PSLS in patients suffering from asymptomatic severe AS in Bangladesh; this is consistent with other studies. Reduced area strain, detectable with 3D-STE, is also consistent with that pattern.
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Affiliation(s)
- Nurun Nahar
- Department of Cardiology, National Heart Foundation Hospital & Research Institute, Dhaka, Bangladesh
| | - Tuhin Haque
- Department of Cardiology, National Heart Foundation Hospital & Research Institute, Dhaka, Bangladesh
| | - Mohammad Kabiruzzaman
- Department of Cardiology, National Heart Foundation Hospital & Research Institute, Dhaka, Bangladesh
| | - Mohammad Abdul Mazid Khan
- Department of Cardiology, National Heart Foundation Hospital & Research Institute, Dhaka, Bangladesh
| | - Sohel Reza Choudhury
- Department of Epidemiology & Research, National Heart Foundation Hospital & Research Institute, Dhaka, Bangladesh
| | - Fazila-Tun-Nesa Malik
- Department of Cardiology, National Heart Foundation Hospital & Research Institute, Dhaka, Bangladesh
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16
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Iung B, Pierard L, Magne J, Messika-Zeitoun D, Pibarot P, Baumgartner H. Great debate: all patients with asymptomatic severe aortic stenosis need valve replacement. Eur Heart J 2023; 44:3136-3148. [PMID: 37503668 DOI: 10.1093/eurheartj/ehad355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Affiliation(s)
- Bernard Iung
- Cardiology Department, Bichat Hospital, APHP, Université Paris Cité, 46 rue Henri Huchard, 75018 Paris, France
| | - Luc Pierard
- Department of Cardiology, University of Liege, Avenue de l´Hopital, 11, B-4000 Liege, Belgium
| | - Julien Magne
- Inserm U1094, IRD U270, University Limoges, CHU Limoges, EpiMaCT-Epidemiology of chronic diseases in tropical zone, Institute of Epidemiology and Tropical Neurology, Omega Health, 2 rue du Dr Marcland, 87025 Limoges, France
- CHU Limoges, Centre of Research and Clinical Data, 2 rue Martin Luther King, 87402 Limoges, France
| | - David Messika-Zeitoun
- Division of Cardiology, University of Ottawa Heart Institute, 40, Rue Ruskin Street, Ottawa, Ontario K1Y 4W7, Canada
| | - Philippe Pibarot
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, 2725, Chemin Saite-Foy, Quebec City, Quebec G1V 4G5, Canada
| | - Helmut Baumgartner
- Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany
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17
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Matsukawa H, Uchida K, Rajbhandari S, Shirakawa M, Yoshimura S. Difference in the cumulative incidence of aneurysmal occlusion by Flow Re-direction Endoluminal Device and Pipeline Embolization Device in the treatment of unruptured internal carotid artery aneurysms: a propensity score-matched cohort study. Neurosurg Rev 2023; 46:125. [PMID: 37243833 DOI: 10.1007/s10143-023-02026-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 04/24/2023] [Accepted: 05/06/2023] [Indexed: 05/29/2023]
Abstract
The introduction of flow diverters (FDs) has represented a paradigm shift in the management of unruptured cerebral aneurysms (UCA). Flow Re-direction Endoluminal Devices (FREDs) and Pipeline Embolization Devices (PEDs) have gained widespread popularity. We aimed to investigate the cumulative incidence of aneurysm occlusion. A total of 195 patients with 199 UCAs were analyzed retrospectively. The outcomes were aneurysmal occlusion during the follow-up, a modified Rankin Scale score of 0-2 at 90 days, additional treatment, major stroke, and steno-occlusive events of FD. Propensity score-matched analysis was performed, controlling for age, sex, aneurysmal size, and location of the internal carotid artery (ICA) aneurysm. Non-ICA aneurysms were excluded from matching. During the follow-up period (median, 366 days), complete and satisfactory aneurysmal occlusions were observed in 128 (68%) and 148 (78%) of 189 UCAs in the unmatched cohort. The 142 (71 each) propensity score-matched cohort was complied. The FRED group had a higher cumulative incidence of ICA aneurysm occlusion (complete: HR 2.7, 95% CI 1.4-5.1, p = 0.0025; satisfactory: HR 2.4, 95% CI 1.1-5.2, p = 0.025). The proportion of additional treatment was significantly smaller in the FRED group (OR 0.077, 95% CI 0.010-0.57, p = 0.0007). Other outcomes showed no significant differences. Propensity score-matched analysis indicated that FRED might have a higher cumulative incidence of aneurysmal occlusion in the treatment of unruptured ICA aneurysms. Whether a cumulative incidence of aneurysmal occlusion may differ by the type of FDs warrants further investigation.
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Affiliation(s)
- Hidetoshi Matsukawa
- Department of Neurosurgery, Takarazuka City Hospital, Takarazuka, Hyogo, Japan
| | - Kazutaka Uchida
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Hyogo, 663-8501, Japan
| | - Saujanya Rajbhandari
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Hyogo, 663-8501, Japan
| | - Manabu Shirakawa
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Hyogo, 663-8501, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Hyogo, 663-8501, Japan.
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Abstract
Patients with chronic kidney disease (CKD) exhibit tremendously elevated risk for cardiovascular disease, particularly ischemic heart disease, due to premature vascular and cardiac aging and accelerated ectopic calcification. The presence of cardiovascular calcification associates with increased risk in patients with CKD. Disturbed mineral homeostasis and diverse comorbidities in these patients drive increased systemic cardiovascular calcification in different manifestations with diverse clinical consequences, like plaque instability, vessel stiffening, and aortic stenosis. This review outlines the heterogeneity in calcification patterning, including mineral type and location and potential implications on clinical outcomes. The advent of therapeutics currently in clinical trials may reduce CKD-associated morbidity. Development of therapeutics for cardiovascular calcification begins with the premise that less mineral is better. While restoring diseased tissues to a noncalcified homeostasis remains the ultimate goal, in some cases, calcific mineral may play a protective role, such as in atherosclerotic plaques. Therefore, developing treatments for ectopic calcification may require a nuanced approach that considers individual patient risk factors. Here, we discuss the most common cardiac and vascular calcification pathologies observed in CKD, how mineral in these tissues affects function, and the potential outcomes and considerations for therapeutic strategies that seek to disrupt the nucleation and growth of mineral. Finally, we discuss future patient-specific considerations for treating cardiac and vascular calcification in patients with CKD-a population in need of anticalcification therapies.
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Affiliation(s)
- Joshua D Hutcheson
- Department of Biomedical Engineering, Florida International University, Miami, FL (J.D.H.)
| | - Claudia Goettsch
- Department of Internal Medicine I, Division of Cardiology, Medical Faculty, RWTH Aachen University, Germany (C.G.)
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19
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Lee G, Chikwe J, Milojevic M, Wijeysundera HC, Biondi-Zoccai G, Flather M, Gaudino MFL, Fremes SE, Tam DY. ESC/EACTS vs. ACC/AHA guidelines for the management of severe aortic stenosis. Eur Heart J 2023; 44:796-812. [PMID: 36632841 DOI: 10.1093/eurheartj/ehac803] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 11/08/2022] [Accepted: 12/19/2022] [Indexed: 01/13/2023] Open
Abstract
Aortic stenosis (AS) is a serious and complex condition, for which optimal management continues to evolve rapidly. An understanding of current clinical practice guidelines is critical to effective patient care and shared decision-making. This state of the art review of the 2021 European Society of Cardiology/European Association for Cardio-Thoracic Surgery Guidelines and 2020 American College of Cardiology/American Heart Association Guidelines compares their recommendations for AS based on the evidence to date. The European and American guidelines were generally congruent with the exception of three key distinctions. First, the European guidelines recommend intervening at a left ventricular ejection fraction of 55%, compared with 60% over serial imaging by the American guidelines for asymptomatic patients. Second, the European guidelines recommend a threshold of ≥65 years for surgical bioprosthesis, whereas the American guidelines employ multiple age categories, providing latitude for patient factors and preferences. Third, the guidelines endorse different age cut-offs for transcatheter vs. surgical aortic valve replacement, despite limited evidence. This review also discusses trends indicating a decreasing proportion of mechanical valve replacements. Finally, the review identifies gaps in the literature for areas including transcatheter aortic valve implantation in asymptomatic patients, the appropriateness of Ross procedures, concomitant coronary revascularization with aortic valve replacement, and bicuspid AS. To summarize, this state of the art review compares the latest European and American guidelines on the management of AS to highlight three areas of divergence: timing of intervention, valve selection, and surgical vs. transcatheter aortic valve replacement criteria.
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Affiliation(s)
- Grace Lee
- Temerty Faculty of Medicine, 1 King's College Circle, Toronto, ON M5S1A8, Canada
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, 127 San Vicente Blvd a3600, Los Angeles, CA 90048, USA
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Heroja Milana Tepića 1, Belgrade, Serbia.,Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Harindra C Wijeysundera
- Schulich Heart Program, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, M4N 3M5, University of Toronto, Toronto, ON, Canada
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Piazzale Aldo Moro, 5, 00185 Roma RM, Italy.,Mediterranea Cardiocentro, Via Orazio, 2, 80122 Napoli, NA, Italy
| | - Marcus Flather
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, UK
| | - Mario F L Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 1300 York Ave, NY New York, USA
| | - Stephen E Fremes
- Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Derrick Y Tam
- Division of Cardiac Surgery, University of Toronto, 200 Elizabeth St., Toronto, ON M5G 2C4, Canada
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20
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Yasmin F, Shaikh A, Asghar MS, Moeed A, Najeeb H, Waqar E, Ram MD, Nankani A, Ochani RK, Aamir M, Ullah W, Waqar F, Johnson DM, Johnson DM. Early Transcatheter or Surgical Aortic Valve Replacement Versus Conservative Management in Asymptomatic Patients With Severe Aortic Stenosis: A Systematic Review and Meta-analysis. Curr Probl Cardiol 2023; 48:101477. [PMID: 36328337 DOI: 10.1016/j.cpcardiol.2022.101477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 10/26/2022] [Indexed: 02/01/2023]
Abstract
The merits of conservative management vs early intervention in patients with asymptomatic severe aortic stenosis remains unknown. Digital databases (MEDLINE, Google Scholar, and Embase) were searched for all relevant studies from inception through September 2022. Studies comparing conservative management with early intervention were compared using a random-effects model to calculate risk ratios (RRs) with 95% confidence interval (CI). A total of 12 studies comprising 3624 asymptomatic aortic stenosis patients (1747 receiving surgery, and 1877 receiving conservative treatment) were included in the analysis. The average follow-up time was 4.45 (IQR 3.5-5) years. Early intervention was associated with a significantly reduced risk of cardiac (RR 0.42, 95% CI 0.25-0.72; P = 0.001; I2 = 54%), non-cardiac (RR 0.46, 95% CI 0.32-0.68; P < 0.0001; I2 = 0%), all-cause mortality (RR 0.40, 95% CI 0.32-0.51; P < 0.00001; I2 = 58%), heart failure hospitalization (RR 0.21, 95% CI 0.13-0.36; P < 0.00001; I2 = 0%), sudden cardiac death (RR 0.29, 95% CI 0.12-0.66; P = 0.004, I2 = 24%), and MACE (RR 0.46, 95% CI; 0.28-0.75; P = 0.002; I2 = 68%), compared with conservative management. There was no significant difference in the 30-day mortality (RR 0.63, 95% CI 0.19-2.04; P = 0.44; I2 = 28%), myocardial infarction (RR 0.44, 95% CI 0.19-1.06; P = 0.07, I2=0%), and 90-day mortality (RR 0.68, 95% CI 0.20-2.37; P = 0.55; I2 = 61%) between the 2 groups. This meta-analysis shows statistically significant reductions in the risk for all-cause mortality, cardiac specific mortality, non-cardiac mortality, heart failure hospitalization, MACE, and sudden cardiac death among asymptomatic aortic stenosis patients who underwent early intervention as opposed to conservative management.
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Affiliation(s)
- Farah Yasmin
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Asim Shaikh
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | | | - Abdul Moeed
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Hala Najeeb
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Eisha Waqar
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Muskaan Doulat Ram
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Avinash Nankani
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Rohan Kumar Ochani
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Muhammad Aamir
- Lehigh Valley Heart Specialists, Lehigh Valley Health Network, Allentown PA
| | - Waqas Ullah
- Division of Cardiology, Sidney Kimmel Medical College, Thomas Jefferson University Hospitals, Philadelphia PA
| | - Fahad Waqar
- Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Drew M Johnson
- Division of Cardiology, Sidney Kimmel Medical College, Thomas Jefferson University Hospitals, Philadelphia PA.
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21
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Matsuda S, Kato T, Morimoto T, Taniguchi T, Minamino-Muta E, Matsuda M, Shiomi H, Ando K, Shirai S, Kanamori N, Murata K, Kitai T, Kawase Y, Izumi C, Miyake M, Mitsuoka H, Kato M, Hirano Y, Nagao K, Inada T, Mabuchi H, Takeuchi Y, Yamane K, Toyofuku M, Ishii M, Inoko M, Ikeda T, Komasa A, Ishii K, Hotta K, Higashitani N, Jinnai T, Kato Y, Inuzuka Y, Morikami Y, Saito N, Minatoya K, Kimura T. Atrial fibrillation in patients with severe aortic stenosis. J Cardiol 2023; 81:144-153. [PMID: 36028354 DOI: 10.1016/j.jjcc.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 07/01/2022] [Accepted: 08/03/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND There has been no previous report evaluating the long impact of atrial fibrillation (AF) on the clinical outcomes stratified by the initial management [conservative or aortic valve replacement (AVR)] strategies of severe aortic stenosis (AS). METHODS We analyzed 3815 patients with severe AS enrolled in the CURRENT AS registry. Patients with AF were defined as those having a history of AF when severe AS was found on the index echocardiography. The primary outcome measure was a composite of aortic valve-related death or hospitalization for heart failure. RESULTS The cumulative 5-year incidence of the primary outcome measure was significantly higher in patients with AF than in those without AF (44.2 % versus 33.2 %, HR 1.54, 95 % CI 1.35-1.76). After adjusting for confounders, the risk of AF relative to no AF remained significant (HR 1.34, 95 % CI 1.16-1.56). The magnitude of excess adjusted risk of AF for the primary outcome measure was greater in the initial AVR stratum (N = 1197, HR 1.95, 95 % CI 1.36-2.78) than in the conservative stratum (N = 2618, HR 1.26, 95 % CI 1.08-1.47) with a significant interaction (p = 0.04). In patients with AF, there was a significant excess adjusted risk of paroxysmal AF (N = 254) relative to chronic AF (N = 528) for the primary outcome measure (HR 1.34, 95 % CI 1.01-1.78). CONCLUSIONS In patients with severe AS, concomitant AF was independently associated with worse clinical outcomes regardless of the initial management strategies. In those patients with conservative strategy, paroxysmal AF is stronger risk factor than chronic AF.
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Affiliation(s)
- Shintaro Matsuda
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takao Kato
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Eri Minamino-Muta
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Mitsuo Matsuda
- Department of Cardiology, Kishiwada City Hospital, Kishiwada, Japan
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kokura, Japan
| | - Shinichi Shirai
- Department of Cardiology, Kokura Memorial Hospital, Kokura, Japan
| | - Norio Kanamori
- Division of Cardiology, Shimada Municipal Hospital, Shimada, Japan
| | - Koichiro Murata
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Takeshi Kitai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center Hospital, Suita, Japan
| | - Yuichi Kawase
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center Hospital, Suita, Japan
| | - Makoto Miyake
- Department of Cardiology, Tenri Hospital, Tenri, Japan
| | - Hirokazu Mitsuoka
- Division of Cardiology, Kindai University Nara Hospital, Ikoma, Japan
| | - Masashi Kato
- Department of Cardiology, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Yutaka Hirano
- Department of Cardiology, Kindai University Hospital, Osakasayama, Japan
| | - Kazuya Nagao
- Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Tsukasa Inada
- Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Hiroshi Mabuchi
- Department of Cardiology, Koto Memorial Hospital, Higashiomi, Japan
| | - Yasuyo Takeuchi
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Keiichiro Yamane
- Department of Cardiology, Kobe City Nishi-Kobe Medical Center, Kobe, Japan
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Mitsuru Ishii
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Moriaki Inoko
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Tomoyuki Ikeda
- Department of Cardiology, Hikone Municipal Hospital, Hikone, Japan
| | - Akihiro Komasa
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Katsuhisa Ishii
- Department of Cardiology, Kansai Electric Power Hospital, Osaka, Japan
| | - Kozo Hotta
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | | | - Toshikazu Jinnai
- Department of Cardiology, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Yoshihiro Kato
- Department of Cardiology, Saiseikai Noe Hospital, Osaka, Japan
| | - Yasutaka Inuzuka
- Department of Cardiology, Shiga General Hospital, Moriyama, Japan
| | - Yuko Morikami
- Department of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan
| | - Naritatsu Saito
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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22
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Costa GNF, Cardoso JFL, Oliveiros B, Gonçalves L, Teixeira R. Early surgical intervention versus conservative management of asymptomatic severe aortic stenosis: a systematic review and meta-analysis. Heart 2023; 109:314-321. [PMID: 36198484 DOI: 10.1136/heartjnl-2022-321411] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 09/26/2022] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE Timing of intervention for patients with asymptomatic severe aortic stenosis (AS) remains controversial. To compare the outcomes of early aortic valve replacement (AVR) versus watchful waiting (WW) in patients with asymptomatic severe AS. METHODS We systematically searched PubMed, Embase and Cochrane databases, in December 2021, for studies comparing early AVR with WW in the treatment of asymptomatic severe AS. Random-effects meta-analysis was performed. RESULTS Twelve studies were included in which two were randomised clinical trials. A total of 4130 patients were included, providing a 1092 pooled death events. Our meta-analysis showed a significantly lower all-cause mortality for the early AVR compared with WW group, although with a high amount of heterogeneity between studies in the magnitude of the effect (pooled OR 0.40; 95% CI 0.35 to 0.45, p<0.01; I²=61%). An early surgery strategy displayed a significantly lower cardiovascular mortality (pooled OR 0.33; 95% CI 0.19 to 0.56, p<0.01; I²=64%) and heart failure hospitalisation (pooled OR 0.19; 95% CI 0.10 to 0.39, p<0.01, I²=7%). However, both groups had similar rates of stroke (pooled OR 1.30; 95% CI 0.73 to 2.29, p=0.36, I²=0%) and myocardial infarction (pooled OR 0.49; 95% CI 0.19 to 1.27, p=0.14, I²= 0%). CONCLUSIONS This study suggests that for patients with asymptomatic severe AS an early surgical intervention compared with a conservative WW strategy was associated with a lower heart failure hospitalisation and a similar rate of stroke or myocardial infarction, although with significant risk of bias. PROSPERO REGISTRATION NUMBER CRD42021291144.
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Affiliation(s)
- Gonçalo Nuno Ferraz Costa
- Serviço de Cardiologia, Centro Hospitalar e Universitario de Coimbra, Coimbra, Portugal .,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | | | | | - Lino Gonçalves
- Serviço de Cardiologia, Centro Hospitalar e Universitario de Coimbra, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Rogerio Teixeira
- Serviço de Cardiologia, Centro Hospitalar e Universitario de Coimbra, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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23
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Taconne M, Le Rolle V, Panis V, Hubert A, Auffret V, Galli E, Hernandez A, Donal E. How myocardial work could be relevant in patients with an aortic valve stenosis? Eur Heart J Cardiovasc Imaging 2022; 24:119-129. [PMID: 35297488 DOI: 10.1093/ehjci/jeac046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 02/22/2022] [Indexed: 12/24/2022] Open
Abstract
AIMS Myocardial work (MW) calculation is an attractive method to assess left ventricular (LV) myocardial function. In case of aortic stenosis (AS), assessment of work indices is challenging because it requires an accurate evaluation of LV-pressure curves. We sought to evaluate the performances of two distinct methods and to provide a quantitative comparison with invasive data. METHODS AND RESULTS Model-based and template-based methods were defined and applied for the evaluation of LV-pressures on 67 AS-patient. Global Constructive (GCW), Wasted (GWW), Positive (GPW), Negative (GNW) MW and Global Work Efficiency (GWE), and Index (GWI) parameters were calculated using the available software computing the indices using brachial blood-pressure and trans-aortic mean pressure gradient (MPG) for estimating the LV-pressures vs. using a model-based and homemade software. A complete comparison was performed with invasive measurements. Patients were characterized by MPG of 49.8 ± 14.8 mmHg, the global longitudinal strain (GLS) was -15.0 ± 4.04%, GCW was 2107 ± 800 mmHg.% (model-based) and 2483 ± 1068 mmHg.% (template-based). The root mean square error (RMSE) and correlation were calculated for each patient and pressure estimation methods. The mean RMSE are 33.9 mmHg and 40.4 mmHg and the mean correlation coefficients are 0.81 and 0.72 for the model-based and template-based methods, respectively. The two methods present correlation coefficient r2 >0.75 for all the indices. CONCLUSION The two non-invasive methods of LV pressure estimation and work indices computation correlate with invasive measurements. Although the model-based approach requires less information and is associated with slightly better performances, the implementation of template-based method is easier and is appropriate for clinical practice.
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Affiliation(s)
- Marion Taconne
- Service de Cardiologie CCPCHU de Rennes, University of Rennes, CHU Rennes, Inserm, LTSI-UMR 1099, Pontchaillou F-35000 Rennes, France
| | - Virginie Le Rolle
- Service de Cardiologie CCPCHU de Rennes, University of Rennes, CHU Rennes, Inserm, LTSI-UMR 1099, Pontchaillou F-35000 Rennes, France
| | - Vasileios Panis
- Service de Cardiologie CCPCHU de Rennes, University of Rennes, CHU Rennes, Inserm, LTSI-UMR 1099, Pontchaillou F-35000 Rennes, France
| | - Arnaud Hubert
- Service de Cardiologie CCPCHU de Rennes, University of Rennes, CHU Rennes, Inserm, LTSI-UMR 1099, Pontchaillou F-35000 Rennes, France
| | - Vincent Auffret
- Service de Cardiologie CCPCHU de Rennes, University of Rennes, CHU Rennes, Inserm, LTSI-UMR 1099, Pontchaillou F-35000 Rennes, France
| | - Elena Galli
- Service de Cardiologie CCPCHU de Rennes, University of Rennes, CHU Rennes, Inserm, LTSI-UMR 1099, Pontchaillou F-35000 Rennes, France
| | - Alfredo Hernandez
- Service de Cardiologie CCPCHU de Rennes, University of Rennes, CHU Rennes, Inserm, LTSI-UMR 1099, Pontchaillou F-35000 Rennes, France
| | - Erwan Donal
- Service de Cardiologie CCPCHU de Rennes, University of Rennes, CHU Rennes, Inserm, LTSI-UMR 1099, Pontchaillou F-35000 Rennes, France
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24
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Jaiswal V, Khan N, Jaiswal A, Dagar M, Joshi A, Huang H, Naz H, Attia AM, Ghanim M, Baburaj A, Song D. Early surgery vs conservative management among asymptomatic aortic stenosis: A systematic review and meta-analysis. IJC HEART & VASCULATURE 2022; 43:101125. [PMID: 36176308 PMCID: PMC9513172 DOI: 10.1016/j.ijcha.2022.101125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/31/2022] [Accepted: 09/17/2022] [Indexed: 11/20/2022]
Abstract
Aortic valve replacement remains the definitive choice of treatment for AS. All-cause mortality and adverse events are lower with early surgical valve repair. In high-risk AS patients, early surgery is safer than conservative management. Early intervention is crucial to prevent irreversible damage of AS.
Introduction Although aortic valve replacement in severe symptomatic Aortic Stenosis (AS) are clearly outlined, the role of surgical intervention in asymptomatic severe AS remains unclear with limited evidence. The aim of our meta-analysis is to evaluate the efficacy and safety of early surgical aortic valve repair compared to conservative management. Methods A systematic literature search was performed in PubMed, Scopus, Embase and Cochrane databases for studies comparing the early surgery versus conservative management among asymptomatic aortic stenosis patients. Unadjusted odds ratios (OR) were pooled using a random-effect model, and a p-value of < 0.05 was considered statistically significant. Results A total of 5 articles (3 observational studies and 2 randomized controlled trials) were included. At a median followup of 4.1 years, here were significantly lower odds of all-cause mortality [OR = 0.30 (95 %CI:0.17–0.53), p < 0.0001], cardiovascular mortality [OR = 0.35 (95 %CI:(0.17–0.72), p = 0.005], and sudden cardiac death (OR = 0.36 (95 %CI: 0.15–0.89), p = 0.03) among early surgery group compared with conservative care. There was no significant difference between incidence of major bleeding, clinical thromboembolic events, hospitalization due to heart failure, stroke and myocardial infarction between the conservative care groups and early surgery. Conclusion Among asymptomatic patients with AS, early surgery shows better outcomes in reducing all-cause mortality and cardiovascular mortality compared with conservative management approaches.
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Affiliation(s)
- Vikash Jaiswal
- Department of Cardiovascular Research, Larkin Community Hospital, FL, USA
| | - Nida Khan
- Jinnah Sindh Medical University, Karachi, Pakistan
| | - Akash Jaiswal
- Department of Geriatric Medicine, All India Institute of Medical Science, New Delhi, India
| | - Mehak Dagar
- Himalayan Institute of Medical Science, Dehradun, India
| | - Amey Joshi
- Department of Cardiovascular Research, Larkin Community Hospital, FL, USA
| | - Helen Huang
- University of Medicine and Health Science, Royal College of Surgeons in Ireland, Dublin, Ireland
- Corresponding author: University of Medicine and Health Science, Royal College of Surgeons in Ireland, 123 St, Stephen Green, Dublin D02 YN77, Ireland.
| | - Hira Naz
- Fatima Jinnah Medical University, Pakistan
| | | | | | - Abiram Baburaj
- Center for Public Health, Queen’s University Belfast, UK
| | - David Song
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai – Elmhurst Hospital Center, NY, USA
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25
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Bezzeccheri A, Vermeersch P, Verheye S, Wilgenhof A, Willemen Y, Vescovo GM, Scott B, Convens C, Zivelonghi C, Agostoni P. Trends and outcomes in transcatheter aortic valve implantation in Belgium: a 13-year single centre experience. Acta Cardiol 2022; 77:960-969. [PMID: 36326198 DOI: 10.1080/00015385.2022.2130444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Transcatheter aortic valve implantation (TAVI) has been adopted as an alternative to surgery in severe aortic stenosis treatment, even in low-intermediate risk. The aim of this study is to retrospectively report our single-centre 13-year TAVI experience with emphasis on learning curve, referral indication and trends in outcomes over time. METHODS We included 361 consecutive patients who underwent TAVI from January 2008 to December 2020, grouped according to similar per-year volume of procedures: G1 (2008-2014), G2 (2015-2017) and G3 (2018-2020). RESULTS The number of procedures increased (group size: 59 vs. 106 vs. 196). No major differences were observed in STS-PROM and EuroSCORE-II between groups, despite TAVI in patients with prior surgical revascularisation was mainly performed in G1. Trans-femoral approach raised from 80.8 to 93.4%, while the most common alternative access was trans-subclavian. The pre-dilation rate was higher in G1 with lower prosthesis post-dilation rate. The length of hospital stay decreased in time by 30%. At 30 days a reduction in all-cause mortality, vascular complications, bleedings and para-valvular leak combined with higher rate of permanent pacing were observed over the groups. At 1-year there was no difference in all-cause mortality but over 30% reduction in cardiovascular death (8.5 vs. 7.5 vs. 5.6%). CONCLUSIONS Favourable trends were observed across the groups, with an improvement in periprocedural outcomes and cardiovascular mortality at 1-year. These improvements could depend on increased expertise because mortality reduction was noted only after reaching a significant procedure volume. A trend towards lower risk patients selection was present in our cohort, as previously described worldwide.
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Affiliation(s)
- Andrea Bezzeccheri
- HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium.,Department of Experimental Medicine, University of Rome 'Tor Vergata', Rome, Italy
| | - Paul Vermeersch
- HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium
| | - Stefan Verheye
- HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium
| | - Adriaan Wilgenhof
- HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium
| | - Yannick Willemen
- HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium
| | | | - Benjamin Scott
- HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium
| | - Carl Convens
- HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium
| | - Carlo Zivelonghi
- HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium
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26
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Wedin JO, Vedin O, Rodin S, Simonson OE, Hörsne Malmborg J, Pallin J, James SK, Flachskampf FA, Ståhle E, Grinnemo KH. Patients With Bicuspid Aortic Stenosis Demonstrate Adverse Left Ventricular Remodeling and Impaired Cardiac Function Before Surgery With Increased Risk of Postoperative Heart Failure. Circulation 2022; 146:1310-1322. [PMID: 35971843 PMCID: PMC9586833 DOI: 10.1161/circulationaha.122.060125] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Differences in adverse cardiac remodeling between patients who have bicuspid (BAV) and tricuspid aortic valve (TAV) with severe isolated aortic stenosis (AS) and its prognostic impact after surgical aortic valve replacement remains unclear. We sought to investigate differences in preoperative diastolic and systolic function in patients with BAV and TAV who have severe isolated AS and the incidence of postoperative heart failure hospitalization and mortality. METHODS Two hundred seventy-one patients with BAV (n=152) or TAV (n=119) and severe isolated AS without coronary artery disease or other valvular heart disease, scheduled for surgical aortic valve replacement, were prospectively included. Comprehensive preoperative echocardiographic assessment of left ventricular (LV) diastolic and systolic function was performed. The heart failure events were registered during a mean prospective follow-up of 1260 days versus 1441 days for patients with BAV or TAV, respectively. RESULTS Patients with BAV had a more pronounced LV hypertrophy with significantly higher indexed LV mass ([LVMi] 134 g/m2 versus 104 g/m2, P<0.001), higher prevalence of LV diastolic dysfunction (72% versus 44%, P<0.001), reduced LV ejection fraction (55% versus 60%, P<0.001), significantly impaired global longitudinal strain (P<0.001), significantly higher NT-proBNP (N-terminal pro-brain natriuretic peptide) levels (P=0.007), and a higher prevalence of preoperative levosimendan treatment (P<0.001) than patients with TAV. LVMi was associated with diastolic dysfunction in both patients with BAV and TAV. There was a significant interaction between aortic valve morphology and LVMi on LV ejection fraction, which indicated a pronounced association between LVMi and LV ejection fraction for patients with BAV and lack of association between LVMi and LV ejection fraction for patients with TAV. Postoperatively, the patients with BAV required significantly more inotropic support (P<0.001). The patients with BAV had a higher cumulative incidence of postoperative heart failure admissions compared with patients with TAV (28.2% versus 10.6% at 6 years after aortic valve replacement, log-rank P=0.004). Survival was not different between patients with BAV and TAV (log-rank P=0.165). CONCLUSIONS Although they were significantly younger, patients with BAV who had isolated severe AS had worse preoperative LV function and an increased risk of postoperative heart failure hospitalization compared with patients who had TAV. Our findings suggest that patients who have BAV with AS might benefit from closer surveillance and possibly earlier intervention.
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Affiliation(s)
- Johan O. Wedin
- Department of Surgical Sciences (J.O.W., S.R., O.E.S., E.S., K.-H.G.), Uppsala University, Sweden.,Department of Cardiothoracic Surgery and Anesthesiology (J.O.W., O.E.S., J.H.M., J.P., E.S., K.-H.G.), Uppsala University Hospital, Sweden
| | - Ola Vedin
- Department of Medical Sciences (O.V., S.K.J., F.A.F.), Uppsala University, Sweden.,Boehringer Ingelheim AB, Stockholm, Sweden (O.V.)
| | - Sergey Rodin
- Department of Surgical Sciences (J.O.W., S.R., O.E.S., E.S., K.-H.G.), Uppsala University, Sweden
| | - Oscar E. Simonson
- Department of Surgical Sciences (J.O.W., S.R., O.E.S., E.S., K.-H.G.), Uppsala University, Sweden.,Department of Cardiothoracic Surgery and Anesthesiology (J.O.W., O.E.S., J.H.M., J.P., E.S., K.-H.G.), Uppsala University Hospital, Sweden
| | - Jonathan Hörsne Malmborg
- Department of Cardiothoracic Surgery and Anesthesiology (J.O.W., O.E.S., J.H.M., J.P., E.S., K.-H.G.), Uppsala University Hospital, Sweden
| | - Johan Pallin
- Department of Cardiothoracic Surgery and Anesthesiology (J.O.W., O.E.S., J.H.M., J.P., E.S., K.-H.G.), Uppsala University Hospital, Sweden
| | - Stefan K. James
- Department of Medical Sciences (O.V., S.K.J., F.A.F.), Uppsala University, Sweden.,Department of Clinical Physiology and Cardiology (S.K.J., F.A.F.), Uppsala University Hospital, Sweden
| | - Frank A. Flachskampf
- Department of Medical Sciences (O.V., S.K.J., F.A.F.), Uppsala University, Sweden.,Department of Clinical Physiology and Cardiology (S.K.J., F.A.F.), Uppsala University Hospital, Sweden
| | - Elisabeth Ståhle
- Department of Surgical Sciences (J.O.W., S.R., O.E.S., E.S., K.-H.G.), Uppsala University, Sweden.,Department of Cardiothoracic Surgery and Anesthesiology (J.O.W., O.E.S., J.H.M., J.P., E.S., K.-H.G.), Uppsala University Hospital, Sweden
| | - Karl-Henrik Grinnemo
- Department of Surgical Sciences (J.O.W., S.R., O.E.S., E.S., K.-H.G.), Uppsala University, Sweden.,Department of Cardiothoracic Surgery and Anesthesiology (J.O.W., O.E.S., J.H.M., J.P., E.S., K.-H.G.), Uppsala University Hospital, Sweden
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27
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Banovic M, Rajani R. Do all patients with asymptomatic severe aortic stenosis need treatment? Expert Rev Cardiovasc Ther 2022; 20:787-793. [PMID: 36243000 DOI: 10.1080/14779072.2022.2137491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
INTRODUCTION Although guidelines recommend a watchful waiting strategy for patients with asymptomatic severe aortic stenosis, there have been considerable advancements in surgical and anaesthetic techniques along with the success of transcatheter aortic valve replacement (AVR) as a viable alternative to surgical AVR. Inevitably, these developments have raised questions as to whether or not there is still merit in waiting for symptoms to ensue before treatment may offered to these patients. AREA COVERED The principal purpose of this paper is to review the data supporting earlier intervention in patients with asymptomatic severe aortic stenosis, and to project the implications these and other ongoing trials will have on indications for AVR in asymptomatic patients in the future. EXPERT OPINION The threshold for intervention in certain subgroups of asymptomatic patients with severe AS has already been lowered. The next frontier will inevitably be determining whether all patients with severe AS should undergo AVR irrespective of their symptomatic status.
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Affiliation(s)
- Marko Banovic
- University Clinical Center of Serbia, Belgrade, Serbia.,Belgrade Medical Faculty, Belgrade, Serbia
| | - Ronak Rajani
- Cardiovascular Directorate, Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Biomedical Engineering and Imaging Sciences, King's College London, UK
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28
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Spilias N, Martyn T, Denby KJ, Harb SC, Popovic ZB, Kapadia SR. Left Ventricular Systolic Dysfunction in Aortic Stenosis: Pathophysiology, Diagnosis, Management, and Future Directions. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2022; 6:100089. [PMID: 37288060 PMCID: PMC10242576 DOI: 10.1016/j.shj.2022.100089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/03/2022] [Accepted: 08/08/2022] [Indexed: 06/09/2023]
Abstract
Degenerative calcific aortic stenosis (AS) is the most common valvular heart disease and often co-exists with left ventricular (LV) systolic dysfunction at the time of diagnosis. Impaired LV systolic function has been associated with worse outcomes in the setting of AS, even after successful aortic valve replacement (AVR). Myocyte apoptosis and myocardial fibrosis are the 2 key mechanisms responsible for the transition from the initial adaptation phase of LV hypertrophy to the phase of heart failure with reduced ejection fraction. Novel advanced imaging methods, based on echocardiography and cardiac magnetic resonance imaging, can detect LV dysfunction and remodeling at an early and reversible stage, with important implications for the optimal timing of AVR especially in patients with asymptomatic severe AS. Furthermore, the advent of transcatheter AVR as a first-line treatment for AS with excellent procedural outcomes, and evidence that even moderate AS portends worse prognosis in heart failure with reduced ejection fraction patients, has raised the question of early valve intervention in this patient population. With this review, we describe the pathophysiology and outcomes of LV systolic dysfunction in the setting of AS, present imaging predictors of LV recovery after AVR, and discuss future directions in the treatment of AS extending beyond the traditional indications defined in the current guidelines.
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Affiliation(s)
| | | | | | | | | | - Samir R. Kapadia
- Address correspondence to: Samir Kapadia, MD, Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Mail Code J2-3, 9500 Euclid Ave, Cleveland, OH 44195.
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29
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Ferlini M, Munafò AR, Lanzillo G, Aiello M, Gazzoli F, Mirizzi AM, Magrini G, Pelenghi S, Visconti LO. Early surgical aortic valve replacement in asymptomatic patients with severe aortic stenosis: a systematic review and meta-analysis. J Cardiovasc Med (Hagerstown) 2022; 23:632-634. [PMID: 35905003 DOI: 10.2459/jcm.0000000000001338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Marco Ferlini
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo
| | | | - Giuseppe Lanzillo
- Department of Molecular Medicine, Unit of Cardiology, University of Pavia, Pavia, Italy
| | - Marco Aiello
- Division of Cardiac Surgery, Fondazione IRCCS Policlinico San Matteo
| | - Fabrizio Gazzoli
- Division of Cardiac Surgery, Fondazione IRCCS Policlinico San Matteo
| | | | - Giulia Magrini
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo
| | - Stefano Pelenghi
- Division of Cardiac Surgery, Fondazione IRCCS Policlinico San Matteo
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30
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Iribarren AC, AlBadri A, Wei J, Nelson MD, Li D, Makkar R, Merz CNB. Sex differences in aortic stenosis: Identification of knowledge gaps for sex-specific personalized medicine. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 21:100197. [PMID: 36330169 PMCID: PMC9629620 DOI: 10.1016/j.ahjo.2022.100197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/18/2022] [Accepted: 08/20/2022] [Indexed: 06/16/2023]
Abstract
Objectives This review summarizes sex-based differences in aortic stenosis (AS) and identifies knowledge gaps that should be addressed by future studies. Background AS is the most common valvular heart disease in developed countries. Sex-specific differences have not been fully appreciated, as a result of widespread under diagnosis of AS in women. Summary Studies including sex-stratified analyses have shown differences in pathophysiology with less calcification and more fibrosis in women's aortic valve. Women have impaired myocardial perfusion reserve and different compensatory response of the left ventricle (LV) to pressure overload, with concentric remodeling and more diffuse fibrosis, in contrast to men with more focal fibrosis and more dilated/eccentrically remodeled LV. There is sex difference in clinical presentation and anatomical characteristics, with women having more paradoxical low-flow/low-gradient AS, under-diagnosis and severity underestimated, with less referral to aortic valve replacement (AVR) compared to men. The response to therapies is also different: women have more adverse events with surgical AVR and greater survival benefit with transcatheter AVR. After AVR, women would have more favorable LV remodeling, but sex-related differences in changes in myocardial reserve flow need future research. Conclusions Investigation into these described sex-related differences in AS offers potential utility for improving prevention and treatment of AS in women and men. To better understand sex-based differences in pathophysiology, clinical presentation, and response to therapies, sex-specific critical knowledge gaps should be addressed in future research for sex-specific personalized medicine.
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Affiliation(s)
- Ana C. Iribarren
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States of America
| | - Ahmed AlBadri
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States of America
| | - Janet Wei
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States of America
- Cedars-Sinai Biomedical Imaging Research Institute, Los Angeles, CA, United States of America
| | - Michael D. Nelson
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States of America
| | - Debiao Li
- Cedars-Sinai Biomedical Imaging Research Institute, Los Angeles, CA, United States of America
| | - Raj Makkar
- Cedars-Sinai Cardiovascular Intervention Center, Smidt Heart Institute, Los Angeles, CA, United States of America
| | - C. Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States of America
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31
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Andersen MJ, Wolsk E, Bakkestrøm R, Christensen N, Carter-Storch R, Omar M, Dahl JS, Frederiksen PH, Borlaug B, Gustafsson F, Hassager C, Moller JE. Pressure–flow responses to exercise in aortic stenosis, mitral regurgitation and diastolic dysfunction. Heart 2022; 108:1895-1903. [PMID: 36356959 PMCID: PMC9664118 DOI: 10.1136/heartjnl-2022-321204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 07/25/2022] [Indexed: 11/25/2022] Open
Abstract
Background Haemodynamic exercise testing is important for evaluating patients with dyspnoea on exertion and preserved ejection fraction. Despite very different pathologies, patients with pressure (aortic stenosis (AS)) and volume (mitral regurgitation (MR)) overload and diastolic dysfunction after recent acute myocardial infarction (AMI) reach similar filling pressure levels with exercise. The pressure–flow relationships (the association between change in cardiac output (∆CO) and change in pulmonary arterial wedge pressure (∆PAWP) may provide insight into haemodynamic adaptation to exercise in these groups. Methods and results One hundred sixty-eight subjects aged >50 years with a left ventricular ejection fraction of ≥50% underwent invasive exercise testing. They were enrolled in four different studies: AS (40 patients), AMI (52 patients), MR (43 patients) and 33 healthy subjects. Haemodynamic data were measured at rest, at 25 W, 75 W and at peak exercise. In all groups, PAWP increased with exercise. The greatest increase was observed in patients with AMI (from 12.7±3.9 mm Hg to 33.1±8.2 mm Hg, p<0.0001) and patients with AS (from 11.8±3.9 mm Hg to 31.4±6.1 mm Hg, p<0.0001), and the smallest was observed in healthy subjects (from 8.3±2.4 mm Hg to 21.1±7.5 mm Hg, p<0.0001). In all groups, the relative pressure increase was greatest at the beginning of the exercise. CO increased most in healthy patients (from 5.3±1.1 to 16.0±3.0 L/min, p<0.0001) and least in patients with AS (from 5.3±1.2 L/min to 12.4±2.6 L/min, p<0.0001). The pressure–flow relationships (∆PAWP/∆CO) and differed among groups (p=0.02). In all groups, the pressure–flow relationship was steepest in the initial phase of the exercise test. The AMI and AS groups (2.3±1.2 mm Hg/L/min and 3.0±1.3 mm Hg/L/min, AMI and AS, respectively) had the largest overall pressure–flow relationship; the healthy group had the smallest initially and at peak exercise (1.3±1.1 mm Hg/L/min) followed by MR group (1.9±1.4 mm Hg/L/min). Conclusion The pressure–flow relationship was steepest in the initial phase of the exercise test in all groups. The pressure–flow relationship differs between groups. Trial registration numbers NCT01974557, NCT01046838, NCT02961647 and NCT02395107.
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Affiliation(s)
- Mads J Andersen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Emil Wolsk
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Rine Bakkestrøm
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | | | | | - Massar Omar
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Jordi S Dahl
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | | | - Barry Borlaug
- Department of Cardiology, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | | | - Jacob E Moller
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
- Department of Cardiology, Odense University Hospital, Odense, Denmark
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32
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Ennezat PV, Malergue MC, Abergel E. Letter by Ennezat et al Regarding Article, "Aortic Valve Replacement Versus Conservative Treatment in Asymptomatic Severe Aortic Stenosis: The AVATAR Trial". Circulation 2022; 146:e44-e45. [PMID: 35939542 DOI: 10.1161/circulationaha.121.058505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Pierre-Vladimir Ennezat
- Department of Cardiology, Groupe Hospitalier Universitaire Henri Mondor, Créteil, France (P-V.E.)
| | | | - Eric Abergel
- Department of Cardiology and Cardiovascular Surgery, Clinique Saint-Augustin, Bordeaux, France (E.A.)
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33
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Narayan P. Management of severe aortic stenosis in asymptomatic patients in the new AVATAR. Indian J Thorac Cardiovasc Surg 2022; 38:454-456. [DOI: 10.1007/s12055-022-01382-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 05/26/2022] [Indexed: 10/18/2022] Open
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34
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Coisne A, Montaigne D, Ninni S, Lamblin N, Lemesle G, Delsart P, Filiot A, Andrey P, Balaye P, Butruille L, Decoin R, Woitrain E, Granada JF, Staels B, Bauters C. Diabetes mellitus and cardiovascular mortality across the spectrum of aortic stenosis. Heart 2022; 108:1815-1821. [PMID: 35697496 DOI: 10.1136/heartjnl-2022-320897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 05/15/2022] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE Current data regarding the impact of diabetes mellitus (DM) on cardiovascular mortality in patients with aortic stenosis (AS) are restricted to severe AS or aortic valve replacement (AVR) trials. We aimed to investigate cardiovascular mortality according to DM across the entire spectrum of outpatients with AS. METHODS Between May 2016 and December 2017, patients with mild (peak aortic velocity=2.5-2.9 m/s), moderate (3-3.9 m/s) and severe (≥4 m/s) AS graded by echocardiography were included during outpatient cardiology visits in the Nord-Pas-de-Calais region in France and followed-up for modes of death between May 2018 and August 2020. RESULTS Among 2703 patients, 820 (30.3%) had DM, mean age was 76±10.8 years with 46.6% of women and a relatively high prevalence of underlying cardiovascular diseases. There were 200 cardiovascular deaths prior to AVR during the 2.1 years (IQR 1.4-2.7) follow-up period. In adjusted analyses, DM was significantly associated with cardiovascular mortality (HR=1.40, 95% CI 1.04 to 1.89; p=0.029). In mild or moderate AS, the cardiovascular mortality of patients with diabetes was similar to that of patients without diabetes. In severe AS, DM was associated with higher cardiovascular mortality (HR=2.65, 95% CI 1.50 to 4.68; p=0.001). This was almost exclusively related to a higher risk of death from heart failure (HR=2.61, 95% CI 1.15 to 5.92; p=0.022) and sudden death (HR=3.33, 95% CI 1.28 to 8.67; p=0.014). CONCLUSION The effect of DM on cardiovascular mortality varied across AS severity. Despite no association between DM and outcomes in patients with mild/moderate AS, DM was strongly associated with death from heart failure and sudden death in patients with severe AS.
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Affiliation(s)
- Augustin Coisne
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille University Hospital Center, Lille, Hauts-de-France, France .,Cardiovascular Research Foundation, New York, New York, USA.,Skirball Center for Innovation, Cardiovascular Research Foundation, New York, New York, USA
| | - David Montaigne
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille University Hospital Center, Lille, Hauts-de-France, France
| | - Sandro Ninni
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille University Hospital Center, Lille, Hauts-de-France, France
| | - Nicolas Lamblin
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur, Lille University Hospital Center, Lille, Hauts-de-France, France
| | - Gilles Lemesle
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur, Lille University Hospital Center, Lille, Hauts-de-France, France
| | - Pascal Delsart
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille University Hospital Center, Lille, Hauts-de-France, France
| | - Alexandre Filiot
- CHU Lille, INCLUDE: Integration Center of the Lille University Hospital for Data Exploration, Lille University Hospital Center, Lille, Hauts-de-France, France
| | - Paul Andrey
- CHU Lille, INCLUDE: Integration Center of the Lille University Hospital for Data Exploration, Lille University Hospital Center, Lille, Hauts-de-France, France
| | - Pierre Balaye
- Univ. Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de santé et des Pratiques médicales, F-59000, Lille University Hospital Center, Lille, Hauts-de-France, France
| | - Laura Butruille
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille University Hospital Center, Lille, Hauts-de-France, France
| | - Raphael Decoin
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille University Hospital Center, Lille, Hauts-de-France, France
| | - Eloise Woitrain
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille University Hospital Center, Lille, Hauts-de-France, France
| | - Juan F Granada
- Cardiovascular Research Foundation, New York, New York, USA.,Skirball Center for Innovation, Cardiovascular Research Foundation, New York, New York, USA
| | - Bart Staels
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille University Hospital Center, Lille, Hauts-de-France, France
| | - Christophe Bauters
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur, Lille University Hospital Center, Lille, Hauts-de-France, France
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Kammoun I, Sghaier A, Bennour E, Laroussi L, Miled M, Neji H, Ben Halima A, Addad F, Marrakchi S, Kachboura S. Current and new imaging techniques in risk stratification of asymptomatic severe aortic stenosis. Acta Cardiol 2022; 77:288-296. [PMID: 34151729 DOI: 10.1080/00015385.2021.1939513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Aortic stenosis (AS) is one of the most common valvular diseases in clinical practice. The prevalence of calcified AS with moderate or severe stenosis exceeds 2% after 75 years. The optimal timing of intervention for asymptomatic severe AS is uncertain and controversial. Identification of high-risk patients is based on echocardiographic parameters (left ventricular dysfunction, AS severity and progression), hemodynamic response to exercise, pulmonary hypertension, and elevated brain natriuretic peptides. However, early surgical aortic valve replacement (AVR), when compared to the watchful waiting approach, was associated with survival advantage. Moreover, new insights into pathophysiology of AS and advances in imaging modalities were helpful in the management of asymptomatic AS. In this report, we detail the potential role of echocardiography to guide timing of surgery and we discussed the use of early risk features based on recent imaging modalities.
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Affiliation(s)
- Ikram Kammoun
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Ahmed Sghaier
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Emna Bennour
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Lobna Laroussi
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Manel Miled
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Henda Neji
- Radiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Afef Ben Halima
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Faouzi Addad
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Sonia Marrakchi
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Salem Kachboura
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
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36
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Evolving Indications of Transcatheter Aortic Valve Replacement—Where Are We Now, and Where Are We Going. J Clin Med 2022; 11:jcm11113090. [PMID: 35683476 PMCID: PMC9180932 DOI: 10.3390/jcm11113090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/04/2022] [Accepted: 05/27/2022] [Indexed: 01/14/2023] Open
Abstract
Indications for transcatheter aortic valve replacement (TAVR) have steadily increased over the last decade since the first trials including inoperable or very high risk patients. Thus, TAVR is now the most common treatment of aortic valve stenosis in elderly patients (vs. surgical aortic valve replacement -SAVR-). In this review, we summarize the current indications of TAVR and explore future directions in which TAVR indications can expand.
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37
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Tsampasian V, Grafton-Clarke C, Gracia Ramos AE, Asimakopoulos G, Garg P, Prasad S, Ring L, McCann GP, Rudd J, Dweck MR, Vassiliou VS. Management of asymptomatic severe aortic stenosis: a systematic review and meta-analysis. Open Heart 2022; 9:e001982. [PMID: 35581008 PMCID: PMC9109115 DOI: 10.1136/openhrt-2022-001982] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/05/2022] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES The management of severe aortic stenosis mandates consideration of aortic valve intervention for symptomatic patients. However, for asymptomatic patients with severe aortic stenosis, recent randomised trials supported earlier intervention. We conducted a systematic review and meta-analysis to evaluate all the available data comparing the two management strategies. METHODS PubMed, Cochrane and Web of Science databases were systematically searched from inception until 10 January 2022. The search key terms were 'asymptomatic', 'severe aortic stenosis' and 'intervention'. RESULTS Meta-analysis of two published randomised trials, AVATAR and RECOVERY, included 302 patients and showed that early intervention resulted in 55% reduction in all-cause mortality (HR=0.45, 95% CI 0.24 to 0.86; I2 0%) and 79% reduction in risk of hospitalisation for heart failure (HR=0.21, 95% CI 0.05 to 0.96; I2 15%). There was no difference in risk of cardiovascular death between the two groups (HR=0.36, 95% CI 0.03 to 3.78; I2 78%). Additionally, meta-analysis of eight observational studies showed improved mortality in patients treated with early intervention (HR=0.38, 95% CI 0.26 to 0.56; I2 77%). CONCLUSION This meta-analysis provides evidence that, in patients with severe asymptomatic aortic stenosis, early intervention reduces all-cause mortality and improves outcomes compared with conservative management. While this is very encouraging, further randomised controlled studies are needed to draw firm conclusions and identify the optimal timing of intervention. PROSPERO REGISTRATION NUMBER CRD42022301037.
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Affiliation(s)
- Vasiliki Tsampasian
- Cardiology, Norfolk and Norwich University Hospital, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Ciaran Grafton-Clarke
- Cardiology, Norfolk and Norwich University Hospital, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Abraham Edgar Gracia Ramos
- Departamento de Medicina Interna, Centro Medico Nacional "La Raza", IMSS, Ciudad de Mexico, Mexico
- Seccion de Estudios de Posgrado e Investigacion, Escuela Superior de Medicina, Instituto Politecnico Nacional, Mexico City, Mexico
| | - George Asimakopoulos
- Cardiology, Royal Brompton and Harefield NHS Trust, London, UK
- School of Medicine, Imperial College London, London, UK
| | - Pankaj Garg
- Cardiology, Norfolk and Norwich University Hospital, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Sanjay Prasad
- Cardiology, Royal Brompton and Harefield NHS Trust, London, UK
- School of Medicine, Imperial College London, London, UK
| | - Liam Ring
- Cardiology, West Suffolk Hospital NHS Trust, Bury Saint Edmunds, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Leicester NIHR Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - James Rudd
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Vassilios S Vassiliou
- Cardiology, Norfolk and Norwich University Hospital, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
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38
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Takeji Y, Taniguchi T, Morimoto T, Shirai S, Kitai T, Tabata H, Kitano K, Ono N, Murai R, Osakada K, Murata K, Nakai M, Tsuneyoshi H, Tada T, Amano M, Shiomi H, Watanabe H, Yoshikawa Y, Yamamoto K, Toyofuku M, Tatsushima S, Kanamori N, Miyake M, Nakayama H, Nagao K, Izuhara M, Nakatsuma K, Inoko M, Fujita T, Kimura M, Ishii M, Usami S, Sawada K, Nakazeki F, Okabayashi M, Shirotani M, Inuzuka Y, Komiya T, Minatoya K, Kimura T. Rationale, Design, and Baseline Characteristics of the CURRENT AS Registry-2. Circ J 2022; 86:1769-1776. [PMID: 35444112 DOI: 10.1253/circj.cj-21-1062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND There is scarce data evaluating the current practice pattern and clinical outcomes for patients with severe aortic stenosis (AS), including both those who underwent surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI) and those who were managed conservatively in the TAVI era.Methods and Results: The Contemporary outcomes after sURgery and medical tREatmeNT in patients with severe Aortic Stenosis (CURRENT AS) Registry-2 is a prospective, physician-initiated, multicenter registry enrolling consecutive patients who were diagnosed with severe AS between April 2018 and December 2020 among 21 centers in Japan. The rationale for the prospective enrollment was to standardize the assessment of symptomatic status, echocardiographic evaluation, and other recommended diagnostic examinations such as computed tomography and measurement of B-type natriuretic peptide. Moreover, the schedule of clinical and echocardiographic follow up was prospectively defined and strongly recommended for patients who were managed conservatively. The entire study population consisted of 3,394 patients (mean age: 81.6 years and women: 60%). Etiology of AS was degenerative in 90% of patients. AS-related symptoms were present in 60% of patients; these were most often heart failure symptoms. The prevalence of high- and low-gradient AS was 58% and 42%, respectively, with classical and paradoxical low-flow low-gradient AS in 4.5% and 6.7%, respectively. CONCLUSIONS The CURRENT AS Registry-2 might be large and meticulous enough to determine the appropriate timing of intervention for patients with severe AS in contemporary clinical practice.
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Affiliation(s)
- Yasuaki Takeji
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | | | | | - Takeshi Kitai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital.,Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | | | - Nobuhisa Ono
- Division of Cardiovascular Surgery, Kokura Memorial Hospital
| | - Ryosuke Murai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Kohei Osakada
- Department of Cardiology, Kurashiki Central Hospital
| | | | - Masanao Nakai
- Department of Cardiovascular Surgery, Shizuoka City Shizuoka Hospital
| | | | | | - Masashi Amano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Hirotoshi Watanabe
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Yusuke Yoshikawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Ko Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center
| | | | | | | | - Hiroyuki Nakayama
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Kazuya Nagao
- Department of Cardiovascular Center, Osaka Red Cross Hospital
| | | | | | - Moriaki Inoko
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital
| | - Takanari Fujita
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center
| | | | - Mitsuru Ishii
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Shunsuke Usami
- Department of Cardiology, Kansai Electric Power Hospital
| | - Kenichiro Sawada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | | | - Manabu Shirotani
- Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine
| | | | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
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39
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Outcomes in Patients With Asymptomatic Aortic Stenosis (from the Evolut Low Risk Trial). Am J Cardiol 2022; 168:110-116. [PMID: 35101271 DOI: 10.1016/j.amjcard.2021.12.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/03/2021] [Accepted: 12/07/2021] [Indexed: 01/04/2023]
Abstract
Transcatheter aortic valve implantation (TAVI) has comparable outcomes with surgical aortic valve replacement (SAVR) in symptomatic patients with severe aortic stenosis, including those at low risk for surgery. Less is known about TAVI outcomes in asymptomatic patients. This analysis compares clinical, hemodynamic, and quality of life (QOL) outcomes after TAVI or SAVR for low-risk asymptomatic patients. The randomized Evolut Low Risk trial enrolled asymptomatic patients treated with TAVI (n = 76) and SAVR (n = 62). New York Heart Association functional class I identified patients without symptoms. Clinical outcomes, echocardiographic findings, and QOL in both groups were compared 30 days and 12 months after AVR. Asymptomatic patients had a mean Society of Thoracic Surgeons score of 1.7 ± 0.6, 73% were men, and mean age was 74.2 ± 5.8 years. The composite end point of all-cause mortality or disabling stroke was similar at 12 months in patients with TAVI (1.3%) and SAVR (6.5%; p = 0.11), although patients with SAVR tended to have higher rates of all-cause mortality (4.8%) compared with patients with TAVI (0.0%, p = 0.05). Patients with TAVI had lower mean aortic valve gradients (8.1 ± 3.2 mm Hg) and larger mean effective orifice area (2.3 ± 0.6 mm Hg) than patients with SAVR (10.8 ± 3.8; p <0.001 and 1.9 ± 0.6; p = 0.001, respectively), and showed significant improvement in Kansas City Cardiomyopathy Questionnaire scores from baseline to 30 days (∆12.1 ± 23.6; p <0.001), whereas patients with SAVR did not (∆2.2 ± 20.3; p = 0.398). Patients with TAVI and SAVR had a significant improvement in QOL by 12 months compared with baseline. In conclusion, low risk asymptomatic patients with severe aortic stenosis who underwent TAVI had comparable clinical outcomes to SAVR, with superior valve performance and faster QOL improvement.
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40
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Affiliation(s)
- Graham S Hillis
- Department of Cardiology, Royal Perth Hospital and Medical School, University of Western Australia, Perth (G.S.H.)
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, United Kingdom (G.P.M.)
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (D.E.N.)
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Surgical aortic valve replacement versus conservative treatment in asymptomatic severe aortic stenosis: An updated systematic review and meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 42:36-44. [DOI: 10.1016/j.carrev.2022.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/17/2022] [Accepted: 03/04/2022] [Indexed: 11/18/2022]
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42
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Banovic M, Putnik S, Penicka M, Doros G, Deja MA, Kockova R, Kotrc M, Glaveckaite S, Gasparovic H, Pavlovic N, Velicki L, Salizzoni S, Wojakowski W, Van Camp G, Nikolic SD, Iung B, Bartunek J. Aortic Valve Replacement Versus Conservative Treatment in Asymptomatic Severe Aortic Stenosis: The AVATAR Trial. Circulation 2022; 145:648-658. [PMID: 34779220 DOI: 10.1161/circulationaha.121.057639] [Citation(s) in RCA: 112] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Surgical aortic valve replacement (SAVR) represents a class I indication in symptomatic patients with severe aortic stenosis (AS). However, indications for early SAVR in asymptomatic patients with severe AS and normal left ventricular function remain debated. METHODS The AVATAR trial (Aortic Valve Replacement Versus Conservative Treatment in Asymptomatic Severe Aortic Stenosis) is an investigator-initiated international prospective randomized controlled trial that evaluated the safety and efficacy of early SAVR in the treatment of asymptomatic patients with severe AS, according to common criteria (valve area ≤1 cm2 with aortic jet velocity >4 m/s or a mean transaortic gradient ≥40 mm Hg), and with normal left ventricular function. Negative exercise testing was mandatory for inclusion. The primary hypothesis was that early SAVR would reduce the primary composite end point of all-cause death, acute myocardial infarction, stroke, or unplanned hospitalization for heart failure compared with a conservative strategy according to guidelines. The trial was designed as event-driven to reach a minimum of 35 prespecified events. The study was performed in 9 centers in 7 European countries. RESULTS Between June 2015 and September 2020, 157 patients (mean age, 67 years; 57% men) were randomly allocated to early surgery (n=78) or conservative treatment (n=79). Follow-up was completed in May 2021. Overall median follow-up was 32 months: 28 months in the early surgery group and 35 months in the conservative treatment group. There was a total of 39 events, 13 in early surgery and 26 in the conservative treatment group. In the early surgery group, 72 patients (92.3%) underwent SAVR with operative mortality of 1.4%. In an intention-to-treat analysis, patients randomized to early surgery had a significantly lower incidence of primary composite end point than those in the conservative arm (hazard ratio, 0.46 [95% CI, 0.23-0.90]; P=0.02). There was no statistical difference in secondary end points, including all-cause mortality, first heart failure hospitalizations, major bleeding, or thromboembolic complications, but trends were consistent with the primary outcome. CONCLUSIONS In asymptomatic patients with severe AS, early surgery reduced a primary composite of all-cause death, acute myocardial infarction, stroke, or unplanned hospitalization for heart failure compared with conservative treatment. This randomized trial provides preliminary support for early SAVR once AS becomes severe, regardless of symptoms. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02436655.
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Affiliation(s)
- Marko Banovic
- Belgrade Medical School, University of Belgrade, Serbia (M.B., S.P.).,Cardiology Department (M.B.), University Clinical Center of Serbia, Belgrade
| | - Svetozar Putnik
- Belgrade Medical School, University of Belgrade, Serbia (M.B., S.P.).,Cardiac-Surgery Department (S.P.), University Clinical Center of Serbia, Belgrade
| | - Martin Penicka
- Cardiovascular Center, OLV Hospital, Aalst, Belgium (M.P., G.V.C., J.B.)
| | - Gheorghe Doros
- Boston University School of Public Health, Department of Biostatistics, MA (G.D.)
| | - Marek A Deja
- Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland (M.A.D.)
| | - Radka Kockova
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (R.K., M.K.)
| | - Martin Kotrc
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (R.K., M.K.)
| | - Sigita Glaveckaite
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Lithuania (S.G.)
| | - Hrvoje Gasparovic
- Department of Cardiac Surgery, University of Zagreb School of Medicine and University Hospital Center Zagreb, Croatia (H.G.)
| | - Nikola Pavlovic
- University Hospital Center Sestre Milosrdnice, Zagreb, Croatia (N.P.)
| | - Lazar Velicki
- Faculty of Medicine, University of Novi Sad, Serbia (L.V.).,Institute of Cardiovascular Diseases Vojvodina, Sremska Kamenica, Serbia (L.V.)
| | - Stefano Salizzoni
- Division of Cardiosurgery, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital and University of Turin, Italy (S.S.)
| | - Wojtek Wojakowski
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland (W.W.)
| | - Guy Van Camp
- Cardiovascular Center, OLV Hospital, Aalst, Belgium (M.P., G.V.C., J.B.)
| | | | - Bernard Iung
- Cardiology Department, Bichat Hospital APHP and Universite de Paris, France (B.I.)
| | - Jozef Bartunek
- Cardiovascular Center, OLV Hospital, Aalst, Belgium (M.P., G.V.C., J.B.)
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43
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Fischlein T, Caporali E, Asch FM, Vogt F, Pollari F, Folliguet T, Kappert U, Meuris B, Shrestha ML, Roselli EE, Bonaros N, Fabre O, Corbi P, Troise G, Andreas M, Pinaud F, Pfeiffer S, Kueri S, Tan E, Voisine P, Girdauskas E, Rega F, García-Puente J, De Kerchove L, Lorusso R. Hemodynamic Performance of Sutureless vs. Conventional Bioprostheses for Aortic Valve Replacement: The 1-Year Core-Lab Results of the Randomized PERSIST-AVR Trial. Front Cardiovasc Med 2022; 9:844876. [PMID: 35252408 PMCID: PMC8894864 DOI: 10.3389/fcvm.2022.844876] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 01/21/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveSutureless aortic valves are an effective option for aortic valve replacement (AVR) showing non-inferiority to standard stented aortic valves for major cardiovascular and cerebral events at 1-year. We report the 1-year hemodynamic performance of the sutureless prostheses compared with standard aortic valves, assessed by a dedicated echocardiographic core lab.MethodsPerceval Sutureless Implant vs. Standard Aortic Valve Replacement (PERSIST-AVR) is a prospective, randomized, adaptive, open-label trial. Patients undergoing AVR, as an isolated or combined procedure, were randomized to receive a sutureless [sutureless aortic valve replacement (Su-AVR)] (n = 407) or a stented sutured [surgical AVR (SAVR)] (n = 412) bioprostheses. Site-reported echocardiographic examinations were collected at 1 year. In addition, a subgroup of the trial population (Su-AVR n = 71, SAVR = 82) had a complete echocardiographic examination independently assessed by a Core Lab (MedStar Health Research Institute, Washington D.C., USA) for the evaluation of the hemodynamic performance.ResultsThe site-reported hemodynamic data of stented valves and sutureless valves are stable and comparable during follow-up, showing stable reduction of mean and peak pressure gradients through one-year follow-up (mean: 12.1 ± 6.2 vs. 11.5 ± 4.6 mmHg; peak: 21.3 ± 11.4 vs. 22.0 ± 8.9 mmHg). These results at 1-year are confirmed in the subgroup by the core-lab assessed echocardiogram with an average mean and peak gradient of 12.8 ± 5.7 and 21.5 ± 9.1 mmHg for Su-AVR, and 13.4 ± 7.7 and 23.0 ± 13.0 mmHg for SAVR. The valve effective orifice area was 1.3 ± 0.4 and 1.4 ± 0.4 cm2 at 1-year for Su-AVR and SAVR. These improvements are observed across all valve sizes. At 1-year evaluation, 91.3% (n = 42) of patients in Su-AVR and 82.3% in SAVR (n = 51) groups were free from paravalvular leak (PVL). The rate of mild PVL was 4.3% (n = 2) in Su-AVR and 12.9% (n = 8) in the SAVR group. A similar trend is observed for central leak occurrence in both core-lab assessed echo groups.ConclusionAt 1-year of follow-up of a PERSIST-AVR patient sub-group, the study showed comparable hemodynamic performance in the sutureless and the stented-valve groups, confirmed by independent echo core lab. Perceval sutureless prosthesis provides optimal sealing at the annulus with equivalent PVL and central regurgitation extent rates compared to sutured valves. Sutureless valves are therefore a reliable and essential technology within the modern therapeutic possibilities to treat aortic valve disease.
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Affiliation(s)
- Theodor Fischlein
- Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
- *Correspondence: Theodor Fischlein
| | - Elena Caporali
- Department of Cardiology, Istituto Cardiocentro Ticino, Lugano, Switzerland
- Department of Cardiac Surgery, Istituto Cardiocentro Ticino, Lugano, Switzerland
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC+), Maastricht, Netherlands
- Elena Caporali
| | - Federico M. Asch
- MedStar Health Research Institute, Washington Hospital Center, Washington D.C., DC, United States
| | - Ferdinand Vogt
- Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
| | - Francesco Pollari
- Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
| | - Thierry Folliguet
- Cardiac Surgery Unit, Hôpital Henri Mondor, Université Paris 12, Créteil, France
| | - Utz Kappert
- Herzzentrum Dresden GmbH Universitätsklinik, Dresden, Germany
| | - Bart Meuris
- Cardiac Surgery Unit, UZ Gasthuisberg Leuven, Leuven, Belgium
| | - Malakh L. Shrestha
- Cardiothoracic and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Eric E. Roselli
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Olivier Fabre
- Lens Hospital and Bois Bernard Private Hospital, Lens, France
| | | | - Giovanni Troise
- Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Frederic Pinaud
- Department of Cardiac Surgery, University Hospital Angers, Angers, France
| | - Steffen Pfeiffer
- Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
| | - Sami Kueri
- University Heart Center Freiburg, Bad Krozingen, Germany
| | - Erwin Tan
- Catharina Ziekenhuis, Eindhoven, Netherlands
| | - Pierre Voisine
- Division of Cardiac Surgery, Quebec Heart and Lung Institute, Quebec, QC, Canada
| | - Evaldas Girdauskas
- University Heart Center Hamburg, Universitätsklinikum Hamburg Eppendorf (UKE), Hamburg, Germany
| | - Filip Rega
- Cardiac Surgery Unit, UZ Gasthuisberg Leuven, Leuven, Belgium
| | | | | | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC+), Maastricht, Netherlands
- Cardiac Surgery, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands
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Kvaslerud AB, Gude E, Eriksen G, Andreassen AK, Gullestad L, Broch K. Diastolic Dysfunction Is Unmasked on Exercise in Patients With Asymptomatic, Severe Aortic Stenosis: An Invasive Hemodynamic Study. Circ Heart Fail 2022; 15:e009253. [PMID: 35137599 DOI: 10.1161/circheartfailure.121.009253] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Optimal timing of aortic valve replacement remains difficult in patients with asymptomatic, severe aortic stenosis (AS). More accurate diagnostic methods are warranted for the detection of subtle ventricular impairment. We aimed to evaluate diastolic function in asymptomatic patients with severe AS. METHODS In this cross-sectional study, patients with asymptomatic, severe AS were evaluated with right heart catheterization at rest and during moderate exercise. The patients also underwent cardiopulmonary exercise testing to objectify functional capacity and confirm the absence of symptoms. RESULTS Between February 2019 and May 2021, we included 50 patients aged 70±12 years. The patients had severe AS with peak velocity 4.4±0.4 m/s, mean gradient 46±9 mm Hg, and an indexed valve area of 0.47±0.08 cm2 at rest. All patients were asymptomatic and had normal left ventricular ejection fraction. Five patients had postcapillary pulmonary hypertension at rest. During exercise, 44 patients (88%) had an increase in the mean pulmonary artery pressure per increase in cardiac output of >3 mm Hg/L per minute, of whom 93% had a concomitant increase in the pulmonary artery wedge pressure per increase in cardiac output >2 mm Hg/L per minute, suggesting exercise-induced pulmonary hypertension due to left heart disease. Female gender and increasing age were associated with a higher increase in the pulmonary artery wedge pressure per increase in cardiac output ratio. The catheterization was well tolerated, and there were no adverse events. CONCLUSIONS A large proportion of asymptomatic patients with severe, degenerative AS have exercise-induced postcapillary pulmonary hypertension.
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Affiliation(s)
- Anette B Kvaslerud
- Department of Cardiology, Rikshospitalet, Oslo University Hospital, Norway (A.B.K., E.G., G.E., A.K.A., L.G., K.B.).,KG Jebsen Center for Cardiac Research, Center for Heart Failure Research, University of Oslo, Norway. (A.B.K., L.G., K.B.).,Faculty of Medicine, University of Oslo, Norway. (A.B.K., L.G., K.B.)
| | - Einar Gude
- Department of Cardiology, Rikshospitalet, Oslo University Hospital, Norway (A.B.K., E.G., G.E., A.K.A., L.G., K.B.)
| | - Gunnar Eriksen
- Department of Cardiology, Rikshospitalet, Oslo University Hospital, Norway (A.B.K., E.G., G.E., A.K.A., L.G., K.B.)
| | - Arne K Andreassen
- Department of Cardiology, Rikshospitalet, Oslo University Hospital, Norway (A.B.K., E.G., G.E., A.K.A., L.G., K.B.)
| | - Lars Gullestad
- Department of Cardiology, Rikshospitalet, Oslo University Hospital, Norway (A.B.K., E.G., G.E., A.K.A., L.G., K.B.).,KG Jebsen Center for Cardiac Research, Center for Heart Failure Research, University of Oslo, Norway. (A.B.K., L.G., K.B.).,Faculty of Medicine, University of Oslo, Norway. (A.B.K., L.G., K.B.)
| | - Kaspar Broch
- Department of Cardiology, Rikshospitalet, Oslo University Hospital, Norway (A.B.K., E.G., G.E., A.K.A., L.G., K.B.).,KG Jebsen Center for Cardiac Research, Center for Heart Failure Research, University of Oslo, Norway. (A.B.K., L.G., K.B.).,Faculty of Medicine, University of Oslo, Norway. (A.B.K., L.G., K.B.)
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Alzaeem H, Abusweireh A. Stress echocardiogram in asymptomatic severe aortic stenosis. Heart Views 2022; 23:33-38. [PMID: 35757449 PMCID: PMC9231544 DOI: 10.4103/heartviews.heartviews_37_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/06/2022] [Indexed: 11/04/2022] Open
Abstract
Aortic stenosis (AS) is one of the most common adult valve diseases. Therefore, current guidelines recommend prompt aortic valve intervention once symptoms occur. However, AS is predominantly a disease of the elderly, and these people may be underreporting their symptoms, have other comorbidities, or have a low level of exertion at the baseline or they might make a subconscious adjustment of their activities. Hence, stress testing can be a vital and objective tool to uncover their symptoms and prognosticate.
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46
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Snir AD, Ng MK, Strange G, Playford D, Stewart S, Celermajer DS. Prevalence and Outcomes of Low-Gradient Severe Aortic Stenosis-From the National Echo Database of Australia. J Am Heart Assoc 2021; 10:e021126. [PMID: 34719256 PMCID: PMC8751961 DOI: 10.1161/jaha.121.021126] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The prevalence and outcomes of the different subtypes of severe low‐gradient aortic stenosis (AS) in routine clinical cardiology practice have not been well characterized. Methods and Results Data were derived from the National Echocardiography Database of Australia. Of 192 060 adults (aged 62.8±17.8 [mean±SD] years) with native aortic valve profiling between 2000 and 2019, 12 013 (6.3%) had severe AS. Of these, 5601 patients (47%) had high‐gradient and 6412 patients (53%) had low‐gradient severe AS. The stroke volume index was documented in 2741 (42.7%) patients with low gradient; 1750 patients (64%) with low flow, low gradient (LFLG); and 991 patients with normal flow, low gradient. Of the patients with LFLG, 1570 (89.7%) had left ventricular ejection fraction recorded; 959 (61%) had paradoxical LFLG (preserved left ventricular ejection fraction), and 611 (39%) had classical LFLG (reduced left ventricular ejection fraction). All‐cause and cardiovascular‐related mortality were assessed in the 8162 patients with classifiable severe AS subtype during a mean±SD follow‐up of 88±45 months. Actual 1‐year and 5‐year all‐cause mortality rates varied across these groups and were 15.8% and 49.2% among patients with high‐gradient severe AS, 11.6% and 53.6% in patients with normal‐flow, low‐gradient severe AS, 16.9% and 58.8% in patients with paradoxical LFLG severe AS, and 30.5% and 72.9% in patients with classical LFLG severe AS. Compared with patients with high‐gradient severe AS, the 5‐year age‐adjusted and sex‐adjusted mortality risk hazard ratios were 0.94 (95% CI, 0.85–1.03) in patients with normal‐flow, low‐gradient severe AS; 1.01 (95% CI, 0.92–1.12) in patients with paradoxical LFLG severe AS; and 1.65 (95% CI, 1.48–1.84) in patients with classical LFLG severe AS. Conclusions Approximately half of those patients with echocardiographic features of severe AS in routine clinical practice have low‐gradient hemodynamics, which is associated with long‐term mortality comparable with or worse than high‐gradient severe AS. The poorest survival was associated with classical LFLG severe AS.
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Affiliation(s)
- Afik D Snir
- Faculty of Medicine and Health University of Sydney Australia
| | - Martin K Ng
- Faculty of Medicine and Health University of Sydney Australia.,Department of Cardiology Royal Prince Alfred Hospital Camperdown Australia
| | - Geoff Strange
- Heart Research Institute Newtown Australia.,School of Medicine University of Notre Dame Fremantle Australia
| | - David Playford
- School of Medicine University of Notre Dame Fremantle Australia
| | - Simon Stewart
- Torrens University Australia Adelaide Australia.,University of Glasgow Scotland
| | - David S Celermajer
- Faculty of Medicine and Health University of Sydney Australia.,Department of Cardiology Royal Prince Alfred Hospital Camperdown Australia.,Heart Research Institute Newtown Australia
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47
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Sevilla T, Revilla-Orodea A, San Román JA. Timing of Intervention in Asymptomatic Patients with Aortic Stenosis. Eur Cardiol 2021; 16:e32. [PMID: 34603512 PMCID: PMC8477179 DOI: 10.15420/ecr.2021.11] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/25/2021] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Teresa Sevilla
- Department of Cardiology, Hospital Clínico Universitario de Valladolid Valladolid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares Madrid, Spain
| | - Ana Revilla-Orodea
- Department of Cardiology, Hospital Clínico Universitario de Valladolid Valladolid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares Madrid, Spain
| | - J Alberto San Román
- Department of Cardiology, Hospital Clínico Universitario de Valladolid Valladolid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares Madrid, Spain
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48
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Vulesevic B, Kubota N, Burwash IG, Cimadevilla C, Tubiana S, Duval X, Nguyen V, Arangalage D, Chan KL, Mulvihill EE, Beauchesne L, Messika-Zeitoun D. Size-adjusted aortic valve area: refining the definition of severe aortic stenosis. Eur Heart J Cardiovasc Imaging 2021; 22:1142-1148. [PMID: 33247914 DOI: 10.1093/ehjci/jeaa295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 10/08/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS Severe aortic valve stenosis (AS) is defined by an aortic valve area (AVA) <1 cm2 or an AVA indexed to body surface area (BSA) <0.6 cm/m2, despite little evidence supporting the latter approach and important intrinsic limitations of BSA indexation. We hypothesized that AVA indexed to height (H) might be more applicable to a wide range of populations and body morphologies and might provide a better predictive accuracy. METHODS AND RESULTS In 1298 patients with degenerative AS and preserved ejection fraction from three different countries and continents (derivation cohort), we aimed to establish an AVA/H threshold that would be equivalent to 1.0 cm2 for defining severe AS. In a distinct prospective validation cohort of 395 patients, we compared the predictive accuracy of AVA/BSA and AVA/H. Correlations between AVA and AVA/BSA or AVA/H were excellent (all R2 > 0.79) but greater with AVA/H. Regressions lines were markedly different in obese and non-obese patients with AVA/BSA (P < 0.0001) but almost identical with AVA/H (P = 0.16). AVA/BSA values that corresponded to an AVA of 1.0 cm2 were markedly different in obese and non-obese patients (0.48 and 0.59 cm2/m2) but not with AVA/H (0.61 cm2/m for both). Agreement for the diagnosis of severe AS (AVA < 1 cm2) was significantly higher with AVA/H than with AVA/BSA (P < 0.05). Similar results were observed across the three countries. An AVA/H cut-off value of 0.6 cm2/m [HR = 8.2(5.6-12.1)] provided the best predictive value for the occurrence of AS-related events [absolute AVA of 1 cm2: HR = 7.3(5.0-10.7); AVA/BSA of 0.6 cm2/m2 HR = 6.7(4.4-10.0)]. CONCLUSION In a large multinational/multiracial cohort, AVA/H was better correlated with AVA than AVA/BSA and a cut-off value of 0.6 cm2/m provided a better diagnostic and prognostic value than 0.6 cm2/m2. Our results suggest that severe AS should be defined as an AVA < 1 cm2 or an AVA/H < 0.6 cm2/m rather than a BSA-indexed value of 0.6 cm2/m2.
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Affiliation(s)
- Branka Vulesevic
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada
| | - Naozumi Kubota
- Department of Cardiology, Juntendo University, Tokyo, Japan
| | - Ian G Burwash
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada
| | - Claire Cimadevilla
- Department of Cardiology and Cardiac Surgery, Assistance Publique - Hôpitaux de Paris, 75018 Paris, France
| | - Sarah Tubiana
- Centre d'Investigations Cliniques, Assistance Publique - Hôpitaux de Paris, 75018 Paris, France
| | - Xavier Duval
- Centre de Ressources Biologiques, Assistance Publique - Hôpitaux de Paris, 75018 Paris, France
| | - Virginia Nguyen
- Department of Cardiology and Cardiac Surgery, Assistance Publique - Hôpitaux de Paris, 75018 Paris, France
| | - Dimitri Arangalage
- Department of Cardiology and Cardiac Surgery, Assistance Publique - Hôpitaux de Paris, 75018 Paris, France
| | - Kwan L Chan
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada
| | - Erin E Mulvihill
- Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, ON K1Y 4W7, Canada
| | - Luc Beauchesne
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada
| | - David Messika-Zeitoun
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada
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49
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Xhepa E, Alvarez-Covarrubias HA, Joner M. Pushing the limits for interventional treatment of aortic valve stenosis. Herz 2021; 46:429-436. [PMID: 34427692 DOI: 10.1007/s00059-021-05057-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2021] [Indexed: 12/19/2022]
Abstract
As we approach 20 years of clinical experience with transcatheter aortic valve replacement (TAVR), a vast portfolio of high-quality clinical data has accumulated, confirming the safety and efficacy of TAVR across the entire spectrum of surgical risk. Although many aspects of this innovative therapy have been thoroughly studied, several challenges remain. As TAVR is expanding to include younger low-risk patients, with longer life expectancy, one major unsolved issue is represented by transcatheter heart valve (THV) durability, since robust THV durability data are currently limited to approximately 5-6 years. Additionally, steric interactions between THV components and coronary ostia may render coronary access particularly difficult, and thus personalized decisions regarding THV type and implanting techniques are of paramount importance to secure future coronary access. Since bicuspid aortic valve (BAV) stenosis may be associated with unfavorable anatomic factors, it has represented an exclusion criterion in major randomized TAVR trials. Albeit promising data are available from multicenter registries, results of specifically designed randomized trials are eagerly needed to inform use of TAVR for BAV stenosis. Although valve-in-valve (ViV) TAVR has emerged as an effective treatment option for degenerated aortic bioprostheses, ViV procedures are associated with specific risks, which mandated the development of specific techniques aimed at reducing the occurrence of periprocedural adverse events. Despite the transfemoral approach represents the access of choice for TAVR, a significant proportion of patients have significant peripheral artery disease and alternative vascular access routes have been increasingly evaluated with encouraging data regarding their safety and feasibility.
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Affiliation(s)
- Erion Xhepa
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Hector A Alvarez-Covarrubias
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Michael Joner
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany. .,Partner Site Munich Heart Alliance, DZHK (German Center for Cardiovascular Research), Munich, Germany.
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50
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Brennan JM, Lowenstern A, Sheridan P, Boero IJ, Thourani VH, Vemulapalli S, Wang TY, Liska O, Gander S, Jager J, Leon MB, Peterson ED. Association Between Patient Survival and Clinician Variability in Treatment Rates for Aortic Valve Stenosis. J Am Heart Assoc 2021; 10:e020490. [PMID: 34387116 PMCID: PMC8475044 DOI: 10.1161/jaha.120.020490] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Patients with symptomatic severe aortic stenosis (ssAS) have a high mortality risk and compromised quality of life. Surgical/transcatheter aortic valve replacement (AVR) is a Class I recommendation, but it is unclear if this recommendation is uniformly applied. We determined the impact of managing cardiologists on the likelihood of ssAS treatment. Methods and Results Using natural language processing of Optum electronic health records, we identified 26 438 patients with newly diagnosed ssAS (2011-2016). Multilevel, multivariable Fine-Gray competing risk models clustered by cardiologists were used to determine the impact of cardiologists on the likelihood of 1-year AVR treatment. Within 1 year of diagnosis, 35.6% of patients with ssAS received an AVR; however, rates varied widely among managing cardiologists (0%, lowest quartile; 100%, highest quartile [median, 29.6%; 25th-75th percentiles, 13.3%-47.0%]). The odds of receiving AVR varied >2-fold depending on the cardiologist (median odds ratio for AVR, 2.25; 95% CI, 2.14-2.36). Compared with patients with ssAS of cardiologists with the highest treatment rates, those treated by cardiologists with the lowest AVR rates experienced significantly higher 1-year mortality (lowest quartile, adjusted hazard ratio, 1.22, 95% CI, 1.13-1.33). Conclusions Overall AVR rates for ssAS were low, highlighting a potential challenge for ssAS management in the United States. Cardiologist AVR use varied substantially; patients treated by cardiologists with lower AVR rates had higher mortality rates than those treated by cardiologists with higher AVR rates.
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Affiliation(s)
- J Matthew Brennan
- Duke Clinical Research Institute Duke University School of Medicine Durham NC
| | - Angela Lowenstern
- Duke Clinical Research Institute Duke University School of Medicine Durham NC
| | - Paige Sheridan
- Department of Family Medicine and Public Health University of California, San Diego School of Medicine San Diego CA.,Boston Consulting Group Boston MA
| | | | - Vinod H Thourani
- Department of Cardiovascular Surgery Piedmont Heart Institute Atlanta GA
| | | | - Tracy Y Wang
- Duke Clinical Research Institute Duke University School of Medicine Durham NC
| | | | | | | | - Martin B Leon
- Columbia University Irving Medical Center and New York Presbyterian Hospital New York NY
| | - Eric D Peterson
- Duke Clinical Research Institute Duke University School of Medicine Durham NC
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