Prognostic Value of E/E′ Ratio in Patients With Unoperated Severe Aortic Stenosis

Comparing Early Intervention to Watchful Waiting: A Review on Risk Stratification and Management in Asymptomatic Aortic Stenosis

Aortic stenosis is a progressive condition with substantial implications for morbidity and mortality. In recent years, attention has shifted toward risk stratification and the development of individualized management plans to optimize treatment outcomes. The management of asymptomatic patients has become a topic of significant controversy, as emerging studies challenge traditional watchful waiting guidelines and propose the potential benefits of early intervention. While early intervention may reduce overall morbidity and mortality in this patient population, the associated procedural risks remain a critical consideration. This review seeks to analyze the existing literature, offering an updated perspective on patient risk stratification and evidence evaluating both management approaches.

High-Gradient Aortic Stenosis With Valve Area >1.0 cm2: The "Forgotten" Discordant Hemodynamic Phenotype

BACKGROUND

Clinical features and outcomes in severe aortic stenosis (AS) have been described according to the hemodynamic phenotypes.

OBJECTIVES

The aim of this study was to investigate the clinical features and prognosis of patients with high-gradient (HG) AS with aortic valve area (AVA) >1.0 cm2.

METHODS

A total of 3,209 patients were identified according to AVA (cm2), peak velocity (m/s), systolic mean pressure gradient (MG) (mm Hg): HG-AVA >1 = >1.0, ≥4, and ≥40, HG-AVA ≤1 = ≤1.0, ≥4, and ≥40; LG-AVA ≤1 (low-gradient) = ≤1.0, <4, and <40; moderate AS = 1.0 

RESULTS

HG-AVA >1 accounted for 230 individuals (7.2%). Compared with others, patients with HG-AVA >1 were younger (70.2 ± 12.0 years), more frequently male (85.7%), had fewer comorbidities, larger body surface area and stroke volume (115 ± 19.3 mL), and had higher prevalence of bicuspid valve (39.6%). After a follow-up of 944 days (Q1-Q3: 27-2,212 days), 1,523 deaths occurred. Compared with the HG-AVA >1 group, all-cause mortality was higher in HG-AVA ≤1 (HR: 1.4; 95% CI: 1.1-1.7), LG-AVA ≤1 (HR: 2.8; 95% CI: 2.2-3.6), and moderate AS (HR: 1.4; 95% CI: 1.1-1.7). These differences were no longer significant after adjustment for age, comorbidities, bicuspid valve, and cardiac function. In the HG-AVA >1 group, patients with aortic valve replacement had better survival outcomes than those without aortic valve replacement (P < 0.001) after balancing the 2 groups.

CONCLUSIONS

The underlying relative high-flow status is responsible for HG in patients with HG-AVA >1. This profile has better prognosis than others, being related to underlying younger age and better general and cardiac conditions, but aortic valve replacement may still benefit these patients.

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Key Words

• aortic stenosis
• echocardiography
• prognosis
• valve disease
• valve gradient

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MESH Headings

• Humans
• Male
• Aortic Valve Stenosis/physiopathology
• Aortic Valve Stenosis/diagnostic imaging
• Aortic Valve Stenosis/mortality
• Aortic Valve Stenosis/surgery
• Female
• Aged
• Hemodynamics
• Aortic Valve/physiopathology
• Aortic Valve/diagnostic imaging
• Aortic Valve/surgery
• Phenotype
• Severity of Illness Index
• Risk Factors
• Aged, 80 and over
• Middle Aged
• Retrospective Studies
• Prognosis
• Time Factors
• Predictive Value of Tests
• Risk Assessment

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Affiliation(s)

Saki Ito Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
Jae K Oh Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
Hector I Michelena Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
Alexander C Egbe Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
Heidi M Connolly Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
Patricia A Pellikka Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
Vuyisile T Nkomo Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
Bradley R Lewis Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
William R Miranda Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.

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Left ventricular diastolic dysfunction in non-myocardial disorders

This article reviews and discusses non-myocardial disorders that represent diagnostic challenges when evaluating patients for suspected heart failure with preserved left ventricular ejection fraction. This includes pre-capillary pulmonary hypertension, which is important to differentiate from post-capillary hypertension caused by left-sided heart disease. The impact of electrical disorders on LV diastolic function is also reviewed, and includes a discussion of left bundle branch, which has both a direct effect on LV diastolic function, as well as a long-term effect due to remodelling. Furthermore, evaluation of diastolic function in patients with atrial fibrillation is discussed. Pericardial diseases are reviewed as well as effects of a normal pericardium on diastolic function in failing hearts. Finally, the article reviews how valvular diseases impact LV diastolic function.

Circulating Plasma Proteins in Aortic Stenosis: Associations With Severity, Myocardial Response, and Clinical Outcomes

BACKGROUND

Echocardiographic indexes of aortic stenosis may not comprehensively reflect disease morbidity. Plasma proteomic profiling may add prognostic value in these patients.

METHODS AND RESULTS

Proximity extension assays (Olink) of 183 circulating cardiovascular and inflammatory proteins were performed in a prospective follow-up study of 122 asymptomatic/minimally symptomatic patients (mean±SD age, 69.1±10.9 years; 61% men) with moderate to severe aortic stenosis and preserved left ventricular ejection fraction. Protein signatures of higher-risk echocardiographic subgroups were determined. Associations of proteins with the primary composite outcome (heart failure hospitalization, progression to New York Heart Association class III-IV, or all-cause mortality) were evaluated using competing risk analyses, with aortic valve replacement being the competing risk. Network analysis unveiled mutually exclusive communities of proteins and echocardiographic parameters, connected only through NT-proBNP (N-terminal pro-B-type natriuretic peptide). Members of the tumor necrosis factor receptor superfamily (TNFRSF1A, TNFRSF1B, and TNFRSF14), and trefoil factor-3 were major hub proteins among the circulating biomarkers. Left ventricular global longitudinal strain >-15% was associated with higher levels of proteins, primarily of inflammation and immune regulation, whereas aortic valve area <1 cm2, E/e' >15, and left atrial reservoir strain <20% were associated with higher levels of NT-proBNP. Of 14 proteins associated with the primary end point, phospholipase-C, C-X-C motif chemokine-9, and interleukin-10 receptor subunit β demonstrated the highest hazard ratios after adjusting for clinical factors (q<0.05).

CONCLUSIONS

Plasma proteins involved in inflammation and immune regulation were differentially expressed in patients with aortic stenosis with reduced left ventricular global longitudinal strain, and associated with adverse clinical outcomes. Their incorporation into aortic stenosis risk stratification warrants further assessment.

Left ventricular strain-volume loops in bicuspid aortic valve disease: new insights in cardiomechanics

Aims

By combining temporal changes in left ventricular (LV) global longitudinal strain (GLS) with LV volume, LV strain-volume loops can assess cardiac function across the cardiac cycle. This study compared LV strain-volume loops between bicuspid aortic valve (BAV) patients and controls, and investigated the loop's prognostic value for clinical events.

Methods and results

From a prospective cohort of congenital heart disease patients, BAV patients were selected and compared with healthy volunteers, who were matched for age and sex at group level. GLS analysis from apical views was used to construct strain-volume loops. Associations with clinical events, i.e. a composite of all-cause mortality, heart failure, arrhythmias, and aortic valve replacement, were assessed by Cox regression. A total of 113 BAV patients were included (median age 32 years, 40% female). BAV patients demonstrated lower Sslope (0.21%/mL, [Q1-Q3: 0.17-0.28] vs. 0.27%/mL [0.24-0.34], P < 0.001) and ESslope (0.19%/mL [0.12-0.25] vs. 0.29%/mL [0.21-0.43], P < 0.001) compared with controls, but also greater uncoupling during early (0.48 ± 1.29 vs. 0.05 ± 1.21, P = 0.04) and late diastole (0.66 ± 1.02 vs. -0.07 ± 1.07, P < 0.001). Median follow-up duration was 9.9 [9.3-10.4] years. Peak aortic jet velocity (HR 1.22, P = 0.03), enlarged left atrium (HR 3.16, P = 0.003), E/e' ratio (HR 1.17, P = 0.002), GLS (HR 1.16, P = 0.008), and ESslope (HR 0.66, P = 0.04) were associated with the occurrence of clinical events.

Conclusion

Greater uncoupling and lower systolic and diastolic slopes were observed in BAV patients compared with healthy controls, suggesting presence of altered LV cardiomechanics. Moreover, lower ESslope was associated with clinical events, highlighting the strain-volume loop's potential as prognostic marker.

Relationship between Preoperative Echocardiographic Parameters and the Incidence of Postoperative Complications in Patients Undergoing Clipping of Unruptured Intracranial Aneurysms: A Retrospective Cohort Study

Background and Objectives: Preoperative echocardiography is widely performed in patients undergoing major surgeries to evaluate cardiac functions and detect structural abnormalities. However, studies on the clinical usefulness of preoperative echocardiography in patients undergoing cerebral aneurysm clipping are limited. Therefore, this study aimed to investigate the correlation between preoperative echocardiographic parameters and the incidence of postoperative complications in patients undergoing clipping of unruptured intracranial aneurysms. Materials and Methods: Electronic medical records of patients who underwent clipping of an unruptured intracranial aneurysm from September 2018 to April 2020 were retrospectively reviewed. Data on baseline characteristics, laboratory variables, echocardiographic parameters, postoperative complications, and hospital stays were obtained. Univariable and multivariable logistic regression analyses were performed to identify independent variables related to the occurrence of postoperative complications and prolonged hospital stay (≥8 d). Results: Among 531 patients included in the final analysis, 27 (5.1%) had postoperative complications. In multivariable logistic regression, the total amount of crystalloids infused (1.002 (1.001-1.003), p = 0.001) and E/e' ratio (1.17 (1.01-1.35), p = 0.031) were significant independent factors associated with the occurrence of a postoperative complication. Additionally, the maximal diameter of a cerebral aneurysm (1.13 (1.02-1.25), p = 0.024), total amount of crystalloids infused (1.001 (1.000-1.002), p = 0.031), E/A ratio (0.22 (0.05-0.95), p = 0.042), and E/e' ratio (1.16 (1.04-1.31), p = 0.011) were independent factors related to prolonged hospitalization. Conclusions: Echocardiographic parameters related to diastolic function might be associated with postoperative complications in patients undergoing clipping of unruptured intracranial aneurysms.

Correlation between artificial intelligence-enabled electrocardiogram and echocardiographic features in aortic stenosis

Aims

An artificial intelligence-enabled electrocardiogram (AI-ECG) is a promising tool to detect patients with aortic stenosis (AS) before developing symptoms. However, functional, structural, or haemodynamic components reflected in AI-ECG responsible for its detection are unknown.

Methods and results

The AI-ECG model that was developed at Mayo Clinic using a convolutional neural network to identify patients with moderate-severe AS was applied. In patients used as the testing group, the correlation between the AI-ECG probability of AS and echocardiographic parameters was investigated. This study included 102 926 patients (63.0 ± 16.3 years, 52% male), and 28 464 (27.7%) were identified as AS positive by AI-ECG. Older age, atrial fibrillation, hypertension, diabetes, coronary artery disease, and heart failure were more common in the positive AI-ECG group than in the negative group (P < 0.001). The AI-ECG was correlated with aortic valve area (ρ = -0.48, R² = 0.20), peak velocity (ρ = 0.22, R² = 0.08), and mean pressure gradient (ρ = 0.35, R² = 0.08). The AI-ECG also correlated with left ventricular (LV) mass index (ρ = 0.36, R² = 0.13), E/e' (ρ = 0.36, R² = 0.12), and left atrium volume index (ρ = 0.42, R² = 0.12). Neither LV ejection fraction nor stroke volume index had a significant correlation with the AI-ECG. Age correlated with the AI-ECG (ρ = 0.46, R² = 0.22) and its correlation with echocardiography parameters was similar to that of the AI-ECG.

Conclusion

A combination of AS severity, diastolic dysfunction, and LV hypertrophy is reflected in the AI-ECG to detect AS. There seems to be a gradation of the cardiac anatomical/functional features in the model and its identification process of AS is multifactorial.

Association of Echocardiographic Parameter E/e' With Cardiovascular Events in a Diverse Population of Inpatients and Outpatients With and Without Cardiac Diseases and Risk Factors

BACKGROUND

The echocardiographic parameter E/e' has been associated with cardiovascular (CV) events. However, few studies have analyzed multiple associated CV outcomes using E/e' in a diverse population of both inpatients and outpatients with and without cardiac diseases and risk factors.

METHODS

Medical records of 75,393 patients without atrial fibrillation (AF) with first available E/e' were retrieved from our hospital database. Patients with mitral valve disease were excluded, and the remainder were studied in protocol 1 (70,819 patients). Patients with hypertension, diabetes mellitus, hyperlipidemia, CV diseases, prior CV events, CV surgeries, and left ventricular ejection fraction <50% or missing left ventricular ejection fraction were further excluded, and the remaining patients were studied in protocol 2 (14,665 patients). The study outcomes are major adverse CV events (MACE), which included myocardial infarction (MI), AF, ischemic and hemorrhagic stroke (IHS), hospitalization for heart failure (HHF), and cardiac death. The primary outcomes were MACE and each of the MACE components.

RESULTS

At the end of maximal 5-year follow-up (median 22.18 months with interquartile range 7.20-49.08 months for MACE in protocol 1 and 23.46 months with interquartile range 8.15-49.02 months for MACE in protocol 2), compared with an E/e' value of <8, an intermediate value of E/e' 8 to 15 and a high value of E/e' >15 were significantly associated with MACE, MI, AF, IHS, HHF, and cardiac death in protocol 1 (all P < .0001). In protocol 2, an intermediate E/e' value of 8 to 15 and a high value of E/e' >15 were significantly associated with MACE, MI, AF, IHS, HHF, and CV death (all P < .05), except an intermediate value E/e' 8 to 15 was not associated with AF.

CONCLUSIONS

In a diverse population of inpatients and outpatients with and without cardiac diseases and risk factors, the echocardiographic parameter E/e' was associated with CV events and is a useful marker of risk.

Growth Differentiation Factor-15 as a Predictor of Functional Capacity, Frailty, and Ventricular Dysfunction in Patients With Aortic Stenosis and Preserved Left Ventricular Ejection Fraction

In aortic stenosis (AS), left ventricular (LV) remodeling often occurs before symptom onset, and early intervention may be beneficial. Risk stratification remains challenging and identification of biomarkers may be useful. We evaluated the association between growth differentiation factor-15 (GDF-15) and soluble suppression of tumorigenicity 2 (sST2) and known markers of poor prognosis in AS. Baseline plasma GDF-15 and sST2 levels were measured in 70 patients with moderate-severe AS (aortic valve area <1.5 cm²) and preserved LV ejection fraction (>45%). Patients were categorized into "low GDF-15" versus "high GDF-15" and "low sST2" versus "high sST2" groups. Groups were compared for differences in cardiovascular risk factors, 6-minute walk test, 5 m gait speed, cognitive function (Montreal Cognitive Assessment), and echocardiographic parameters. Overall, 44% of patients were deemed asymptomatic by New York Heart Association class, 61% had severe AS (aortic valve area <1 cm²) and all patients had preserved LV ejection fraction. GDF-15 levels were not predictive of AS severity. However, high GDF-15 (>1,050 pg/ml) was associated with LV dysfunction as shown by lower indexed stroke volume (p <0.01), worse LV global longitudinal strain (p = 0.04), greater mean E/e' (p = 0.02) and indexed left atrial volume (p <0.01). It was also associated with decreased functional capacity with shorter 6-minute walk test (p = 0.01) and slower 5 m gait speed (p = 0.02). Associations between sST2 levels and markers of poor prognosis were less compelling. In this study of patients with moderate to severe AS, elevated GDF-15 levels are associated with impaired functional capacity, poorer performance on fragility testing, and LV dysfunction. In conclusion, GDF-15 may integrate these markers of adverse outcomes into a single biomarker of poor prognosis.

Prognostic Value of Left Atrial Strain in Aortic Stenosis: A Competing Risk Analysis

BACKGROUND

The role of left atrial (LA) strain as an imaging biomarker in aortic stenosis is not well established. The aim of this study was to investigate the prognostic performance of phasic LA strain in relation to clinical and echocardiographic variables and N-terminal pro-B-type natriuretic peptide in asymptomatic and minimally symptomatic patients with moderate to severe aortic stenosis and left ventricular ejection fraction > 50%.

METHODS

LA reservoir strain (LASr), LA conduit strain (LAScd), and LA contractile strain (LASct) were measured using speckle-tracking echocardiography. The primary outcome was a composite of all-cause mortality, heart failure hospitalization, progression to New York Heart Association functional class III or IV, acute coronary syndrome, or syncope. Secondary outcomes 1 and 2 comprised the same end points but excluded acute coronary syndrome and additionally syncope, respectively. The prognostic performance of phasic LA strain cutoffs was evaluated in competing risk analyses, aortic valve replacement being the competing risk.

RESULTS

Among 173 patients (mean age, 69 ± 11 years; mean peak transaortic velocity, 4.0 ± 0.8 m/sec), median LASr, LAScd, and LASct were 27% (interquartile range [IQR], 22%-32%), 12% (IQR, 8%-15%), and 16% (IQR, 13%-18%), respectively. Over a median of 2.7 years (IQR, 1.4-4.6 years), the primary outcome and secondary outcomes 1 and 2 occurred in 66 (38%), 62 (36%), and 59 (34%) patients, respectively. LASr < 20%, LAScd < 6%, and LASct < 12% were identified as optimal cutoffs of the primary outcome. In competing risk analyses, progressing from echocardiographic to echocardiographic-clinical and combined models incorporating N-terminal pro-B-type natriuretic peptide, LA strain parameters outperformed other key echocardiographic variables and significantly predicted clinical outcomes. LASr < 20% was associated with the primary outcome and secondary outcome 1, LAScd < 6% with all clinical outcomes, and LASct < 12% with secondary outcome 2. LAScd < 6% had the highest specificity (95%) and positive predictive value (82%) for the primary outcome, and competing risk models incorporating LAScd < 6% had the best discriminative value.

CONCLUSIONS

In well-compensated patients with moderate to severe aortic stenosis and preserved left ventricular ejection fractions, LA strain was superior to other echocardiographic indices and incremental to N-terminal pro-B-type natriuretic peptide for risk stratification. LAScd < 6%, LASr < 20%, and LASct < 12% identified patients at higher risk for adverse outcomes.

Aortic Stenosis: New Insights in Diagnosis, Treatment, and Prevention

Aortic stenosis (AS) is one of the most common valvular heart diseases and the number of patients with AS is expected to increase globally as the older population is growing fast. Since the majority of patients are elderly, AS is no longer a simple valvular heart disease of left ventricular outflow obstruction but is accompanied by other cardiac and comorbid conditions. Because of the significant variations of the disease, identifying patients at high risk and even earlier detection of patients with AS before developing symptomatic severe AS is becoming increasingly important. With the proven of efficacy and safety of transcatheter aortic valve replacement (TAVR) in the severe AS population, there is a growing interest in applying TAVR in those with less than severe AS. A medical therapy to reduce or prevent the progression in AS is actively investigated by several randomized control trials. In this review, we will summarize the most recent findings in AS and discuss potential future management strategies of patients with AS.

Left ventricular remodelling patterns in patients with moderate aortic stenosis

AIMS

Moderate aortic stenosis (AS) is associated with an increased risk of adverse events. Because outcomes in patients with AS are ultimately driven by the condition of the left ventricle (LV) and not by the valve, assessment of LV remodelling seems important for risk stratification. This study evaluated the association between different LV remodelling patterns and outcomes in patients with moderate AS.

METHODS AND RESULTS

Patients with moderate AS (aortic valve area 1.0-1.5 cm2) were identified and stratified into four groups according to the LV remodelling pattern: normal geometry (NG), concentric remodelling (CR), concentric hypertrophy (CH), or eccentric hypertrophy (EH). Clinical outcomes were defined as all-cause mortality and a composite endpoint of all-cause mortality and aortic valve replacement (AVR). Of 1931 patients with moderate AS (age 73 ± 10 years, 52% men), 344 (18%) had NG, 469 (24%) CR, 698 (36%) CH, and 420 (22%) EH. Patients with CH and EH showed higher 3-year mortality rates (28% and 32%, respectively) when compared with patients with NG (19%) (P < 0.001). After multivariable adjustment, CH remained independently associated with mortality (HR 1.258, 95% CI 1.016-1.558; P = 0.035), whereas both CH (HR 1.291, 95% CI 1.088-1.532; P = 0.003) and EH (HR 1.217, 95% CI 1.008-1.470; P = 0.042) were associated with the composite endpoint of death or AVR.

CONCLUSION

In patients with moderate AS, those who develop CH already have an increased risk of all-cause mortality. Assessment of the LV remodelling patterns may identify patients at higher risk of adverse events, warranting closer surveillance, and possibly earlier intervention.

Sex-Related Differences in Medically Treated Moderate Aortic Stenosis

Background

Recent data showed poor long-term survival in patients with moderate AS. Although sex differences in left ventricular (LV) remodeling and outcome are well described in severe AS, it has not been evaluated in moderate AS.

Methods

In this retrospective, multicenter study, patients with a first diagnosis of moderate AS diagnosed between 2001 and 2019 were identified. Clinical and echocardiographic parameters were recorded at baseline and compared between men and women. Patients were followed up for the primary endpoint of all-cause mortality with censoring at the time of aortic valve replacement.

Results

A total of 1895 patients with moderate AS (age 73 ± 10 years, 52% male) were included. Women showed more concentric hypertrophy and had more pronounced LV diastolic dysfunction than men. During a median follow-up of 34 (13-60) months, 682 (36%) deaths occurred. Men showed significantly higher mortality rates at 3- and 5-year follow-up (30% and 48%, respectively) than women (26% and 39%, respectively) (p = 0.011). On multivariable analysis, male sex remained independently associated with mortality (hazard ratio 1.209; 95% CI: 1.024-1.428; p = 0.025). LV remodeling (according to LV mass index) was associated with worse outcomes (hazard ratio 1.003; CI: 1.001-1.005; p = 0.006), but no association was observed between the interaction of LV mass index and sex with outcomes.

Conclusions

LV remodeling patterns are different between men and women having moderate AS. Male sex is associated with worse outcomes in patients with medically treated moderate AS. Further studies investigating the management of moderate AS in a sex-specific manner are needed.

Peri-operative changes in diastolic function and outcomes in congenital aortic valve surgery

Background

The ratio of early diastolic mitral inflow velocity (E) to early diastolic mitral annular tissue velocity (e’), or E/e’, is an echocardiographic measure of left ventricular filling pressure. Peri‐operative changes in E/e’ and association with outcomes have been demonstrated in adults undergoing surgery for aortic stenosis (AS). We sought to explore changes in E/e’ and other diastolic indices in the setting of congenital AS surgery and to assess for association with post‐operative outcomes among children and young adults.

Methods

A retrospective, single‐center study was performed among patients 6 months to 30 years of age who underwent congenital AS surgery from 2006 to 2018. Tissue Doppler indices were collected from pre‐ and post‐operative echocardiograms. Post‐operative outcomes were reviewed.

Results

Sixty‐six subjects with subvalvar (45%), valvar (47%), and supravalvar (8%) AS underwent surgery at a median age of 9.5 years (IQR: 4.0–14.8). Pre‐operatively, the lateral E/e’ ratio was 8.6 (6.7–11.0); 33% had E/e’≥10. Post‐operatively, the lateral e’ decreased to 9.9 cm/s (8.0–11.4), the E/e’ ratio increased to 10.4 (8.3–13.1); and 53% had E/e’≥10 (p‐values < 0.0001, 0.0072, and < 0.001, respectively). Pre‐operative lateral e’ correlated modestly with duration of intubation (ρ = −0.24, p‐value 0.048) and post‐operative lateral e’ correlated modestly with duration of intubation and length of hospital stay (ρ = −0.28 and −0.26, p‐values = 0.02 and 0.04, respectively).

Conclusions

Children and young adults who underwent congenital AS surgery had echocardiographic evidence of diastolic dysfunction pre‐operatively that worsened post‐operatively. Lateral e’ may be a sensitive indicator of impaired ventricular relaxation in these patients and may impact duration of intubation and hospital stay.

Assessment of diastolic function in aortic stenosis: A comparison between 2009 and 2016 guidelines

AIMS

New diastolic dysfunction (DD) guidelines were introduced in 2016 to replace the 2009 guidelines, but have not yet been evaluated in aortic stenosis (AS). We aimed to compare the 2009 and 2016 DD guidelines in severe AS patients in terms of association with left ventricular (LV) and left atrial (LA) remodeling, with pulmonary capillary wedge pressure (PCWP) at rest and exercise, and with prognosis.

METHODS AND RESULTS

We included 212 patients with severe AS (112 undergoing AVR, 100 asymptomatic). Echocardiography, magnetic resonance imaging, and brain natriuretic peptides (BNP) were performed/measured. Thirty-nine asymptomatic patients had PCWP measured during rest and maximal exertion. Asymptomatic patients were followed for 3.1 years for the combined endpoint of death, AVR or admission with heart failure. The 2009 and 2016 DD guidelines agreed poorly with each other (Cohens' κ = .15). 2009 guidelines showed many ambiguous DD findings. With the 2016 guidelines, 20% of patients had indeterminate DD. DD grade 2 according to 2016 guidelines showed stronger association with symptom status, BNP, global longitudinal strain (GLS) and peak exercise PCWP than 2009 guidelines. For indeterminate DD patients according to 2009 guidelines, GLS above the median was associated with event-free survival (HR .11 (95% CI .02-.53)). For neither guideline was DD associated with the combined endpoint in asymptomatic patients.

CONCLUSION

The 2016 guidelines show a stronger association with BNP, GLS, and exercise PCWP than the 2009 guidelines. The 2016 guidelines result in 20% of patients with indeterminate DD; however, these patients may possibly be stratified according to GLS.

Long-term Implications of Post-Procedural Left Ventricular End-Diastolic Pressure in Patients Undergoing Transcatheter Aortic Valve Implantation

Current risk models have only limited accuracy in predicting transcatheter aortic valve Implantation (TAVI) outcomes and there is a paucity of clinical variables to guide patient management after the procedure. The prognostic impact of elevated left ventricular end-diastolic pressure (LVEDP) in TAVI patients is unknown. The aim of the present study was to evaluate the prognostic value of after-procedural LVEDP in patients who undewent TAVI. Consecutive patients with severe symptomatic aortic stenosis who undewent TAVI were divided into 2 groups according to after-procedural LVEDP above and below or equal 12 mm Hg. Collected data included baseline clinical, laboratory and echocardiographic variables. We evaluated the impact of elevated vs. normal LVEDP on in-hospital outcomes, short- and long-term mortality. Eight hundred forty-five patients were included in the study with complete in-hospital and late mortality data available for all survivors (median follow-up 29.5 months [IQR 16.5 to 48.0]). The mean age (±SD) was 82.3±6.2 years and mean Society of Thoracic Surgery score was 4.0%±3.0%. Patients with LVEDP>12 mm Hg (n = 591, 70%) and LVEDP≤12 mm Hg (n = 254, 30%) had a 6-months mortality rate of 6.8% and 2%, respectively (P=0.004) and a 1-year mortality rate of 10.1% vs 4.9%, respectively (p = 0.017). By multivariable analysis, after-procedural LVEDP>12 mm Hg was independently associated with all-cause mortality (HR 2.45, 95% CI 1.58 to 3.76, p <0.001) during long-term follow-up. In conclusion, elevated after-procedural LVEDP in patients who undewent TAVI is an independent predictor of mortality following TAVI. Further research regarding the use of LVEDP as a tool for after-procedural medical management is warranted.

Markers of Elevated Left Ventricular Filling Pressure Are Associated with Increased Mortality in Nonsevere Aortic Stenosis

BACKGROUND

Echocardiographic measures of elevated left ventricular filling pressures are associated with an adverse prognosis. The aim of this study was to determine the relationship between acute (ratio of early transmitral flow to mitral annular velocity [E/e']) and chronic (indexed left atrial volume) markers of left ventricular filling pressure and mortality in patients with nonsevere aortic stenosis (AS), within the National Echo Database Australia cohort, testing the hypothesis that they would reflect the early hemodynamic consequences of AS and be associated with increased mortality in this setting.

METHODS

The first record for patients ≥18 years of age showing hemodynamically significant but nonsevere (mild or moderate) AS (mean pressure gradient ≥ 10 to <40 mm Hg and aortic valve area > 1 cm²) was analyzed. Baseline demographics and echocardiographic variables were compared with those among patients without AS (mean pressure gradient < 10 mm Hg). Mortality linkage data were available for all patients.

RESULTS

Of 78,886 patients with aortic valve mean pressure gradients < 40 mm Hg and aortic valve areas > 1 cm², 13,768 (17%) were identified with nonsevere AS (aortic valve mean pressure gradient 10-40 mm Hg), of whom 57% were men (mean age, 73 ± 13.4 years) with a median follow-up of 3.4 years (interquartile range, 1.7-6.1 years). In unadjusted time-varying coefficient models, nonsevere AS and indexed left atrial volume > 34 mL/m² (hazard ratio [HR], 2.29; 95% CI, 2.03-2.58), E/e' ratio > 14 (HR, 2.27; 95% CI, 2.08-2.49), left ventricular ejection fraction < 50% (HR, 2.82; 95% CI, 2.50-3.19), and tricuspid regurgitation peak velocity > 280 cm/sec (HR, 2.54; 95% CI, 2.30-2.80) were associated with increased mortality hazard at the time of echocardiography. All markers were significant when combined in a multivariate model.

CONCLUSIONS

Indices of elevated left ventricular filling pressure are independently associated with death in patients with nonsevere AS. Risk stratification models incorporating these variables may identify patients at risk for complications, warranting closer surveillance and possibly earlier intervention.

"Pure" severe aortic stenosis without concomitant valvular heart diseases: echocardiographic and pathophysiological features

Purpose

In echocardiography the severity of aortic stenosis (AS) is defined by effective orifice area (EOA), mean pressure gradient (mPG_AV) and transvalvular flow velocity (maxV_AV). The hypothesis of the present study was to confirm the pathophysiological presence of combined left ventricular hypertrophy (LVH), diastolic dysfunction (DD) and pulmonary artery hypertension (PAH) in patients with “pure” severe AS.

Methods and Results

Patients (n = 306) with asymptomatic (n = 133) and symptomatic (n = 173) “pure” severe AS (mean age 78 ± 9.5 years) defined by indexed EOA < 0.6 cm² were enrolled between 2014 and 2016. AS patients were divided into 4 subgroups according to mPG_AV and indexed left ventricular stroke volume: low flow (LF) low gradient (LG)-AS (n = 133), normal flow (NF) LG-AS (n = 91), LF high gradient (HG)-AS (n = 21) and NFHG-AS (n = 61). Patients with “pure” severe AS showed mean mPG_AV of 31.7 ± 9.1 mmHg and mean maxV_AV of 3.8 ± 0.6 m/s. Only 131 of 306 patients (43%) exhibited mPG_AV > 40 mmHg and maxV_AV > 4 m/s documenting incongruencies of the AS severity assessment by Doppler echocardiography. LVH was documented in 81%, DD in 76% and PAH in 80% of AS patients. 54% of “pure” AS patients exhibited all three alterations. Ranges of mPG_AV and maxV_AV were higher in patients with all three alterations compared to patients with less than three. 224 (73%) patients presented LG-conditions and 82 (27%) HG-conditions. LVH was predominant in NF-AS (p = 0.014) and PAH in LFHG-AS (p = 0.014). Patients’ treatment was retrospectively assessed (surgery: n = 100, TAVI: n = 48, optimal medical treatment: n = 156).

Conclusion

In patients with “pure” AS according to current guidelines the presence of combined LVH, DD and PAH as accepted pathophysiological sequelae of severe AS cannot be confirmed. Probably, the detection of these secondary cardiac alterations might improve the diagnostic algorithm to avoid overestimation of AS severity.

Predictive value of left ventricular diastolic chamber stiffness in patients with severe aortic stenosis undergoing aortic valve replacement

Aims

Despite improvements in cardiac haemodynamics and symptoms, long-term mortality remains increased in some patients after aortic valve replacement (AVR). Limited data exist on the prognostic role of left ventricular (LV) chamber stiffening in these patients.

Methods and results

We performed a retrospective analysis in 1893 patients with severe aortic stenosis (AS) referred for AVR. LV end-diastolic pressure–volume relations (EDPVR, P = αV^β) were reconstructed from echocardiographic measurements of end-diastolic volumes and estimates of end-diastolic pressure (EDP). The impact of EDPVR-derived LV chamber stiffness (CS30, at 30 mmHg EDP) on all-cause mortality after AVR was evaluated. Mean age was 76 ± 10 years, 39% were females, and ejection fraction (EF) was 61 ± 12%. The mean LV chamber stiffness (CS30) was 2.2 ± 1.3 mmHg/mL. A total of 877 (46%) patients had high LV stiffness (CS30 &gt;2 mmHg/mL). In these patients, the EDPVR curves were steeper and shifted leftwards, indicating higher stiffness at all pressure levels. These patients were slightly older, more often female, and had more prevalent comorbidities compared to patients with low stiffness. At follow-up [median 4.2 (interquartile range 2.8–6.3) years; 675 deaths], a higher CS30 was associated with lower survival (hazard ratio: 2.7 for severe vs. mild LV stiffening; P &lt; 0.0001), both in patients with normal or reduced EF. At multivariate analysis, CS30 remained an independent predictor, even after adjusting for age, sex, comorbidities, EF, LV remodelling, and diastolic dysfunction.

Conclusion

Higher preoperative LV chamber stiffening in patients with severe AS is associated with poorer outcome despite successful AVR.

Expert consensus document on the assessment of the severity of aortic valve stenosis by echocardiography to provide diagnostic conclusiveness by standardized verifiable documentation

According to recent recommendations on echocardiographic assessment of aortic valve stenosis direct measurement of transvalvular peak jet velocity, calculation of transvalvular mean gradient from the velocities using the Bernoulli equation and calculation of the effective aortic valve area by continuity equation are the appropriate primary key instruments for grading severity of aortic valve stenosis. It is obvious that no gold standard can be declared for grading the severity of aortic stenosis. Thus, conclusions of the exclusive evaluation of aortic stenosis by Doppler echocardiography seem to be questionable due to the susceptibility to errors caused by methodological limitations, mathematical simplifications and inappropriate documentation. The present paper will address practical issues of echocardiographic documentation to satisfy the needs to analyze different scenarios of aortic stenosis due to various flow conditions and pressure gradients. Transesophageal and multidimensional echocardiography should be implemented for reliable measurement of geometric aortic valve area and of cardiac dimensions at an early stage of the diagnostic procedure to avoid misinterpretation due to inconsistent results.

Association between left ventricular diastolic function and right ventricular function and morphology in asymptomatic aortic stenosis

Background

Aortic stenosis (AS) is a progressive disease in which left ventricular (LV) diastolic dysfunction is common. However, the association between diastolic dysfunction and right ventricular (RV) loading conditions and function has not been investigated in asymptomatic AS patients.

Methods and findings

A total of 41 patients underwent right heart catheterization and simultaneous echocardiography at rest and during maximal supine exercise, stratified according to resting diastolic function. Cardiac chamber size and morphology was assessed using cardiac magnetic resonance imaging (cMRI). RV stroke work index, pulmonary artery (PA) compliance, PA elastance, PA pulsatility index, and right atrial pressure (RAP) were calculated at rest and maximal exercise. Ten patients (24%) had normal LV filling pattern, 20 patients (49%) had grade 1, and 11 patients (27%) had grade 2 diastolic dysfunction. Compared to patients with normal diastolic filling pattern, patients with diastolic dysfunction had lower RV end-diastolic volume (66 ± 11 ml/m² vs. 79 ± 15 ml/m², p = 0.02) and end-systolic volume (25 ± 7 ml/m² vs. 32 ± 9 ml/m², p = 0.04). An increase in mean RAP to ≥15 mmHg following exercise was not seen in patients with normal LV filling, compared to 4 patients (20%) with mild and 7 patients (63%) with moderate diastolic dysfunction (p = 0.003). PA pressure and PA elastance was increased in grade 2 diastolic dysfunction and correlated with RV volume and maximal oxygen consumption (r = -0.71, p < 0.001).

Conclusions

Moderate diastolic dysfunction is associated with increased RV afterload (elastance), which is compensated at rest, but is associated with increased RAP and inversely related to maximal oxygen consumption during maximal exercise.

Left atrial strain and distensibility in relation to left ventricular dysfunction and prognosis in aortic stenosis

OBJECTIVE

To test the relationship between left atrial (LA) distensibility (LAD), LA strain (LAS), and left ventricular (LV) dysfunction and prognosis in aortic stenosis (AS).

METHODS

Transthoracic Doppler echocardiography was performed prospectively in 102 consecutive patients with AS (77 with severe, 25 with moderate, mean age 77 years). LA volume was calculated by the area-length method in apical four- and two-chamber views, immediately before mitral valve opening (Vol_max ) and at mitral valve closure (Vol_min ). LAD was defined as (Vol_max   - Vol_min ) × 100%/Vol_min . LAS (mean of maximal strain from the 4-2 chamber views) was conducted using a dedicated software package. The endpoint was hospitalization for heart failure and death from any cause.

RESULTS

Left atrial strain, LAD, and LA vol/m² were significantly correlated with LV diastolic parameters, and PASP (all, P < 0.05). However, LAD and LAS but not LA vol/m² were significantly correlated with Charlson score, LV global longitudinal strain, and to transaortic mean gradient (all, P < 0.05). At a median follow-up of 25 months, 53 patients had an event. LAS, LAD, LA vol/m², and Charlson index were associated with events (all, P < 0.05). In multivariate analysis, LAD, LAS, and Charlson index (all, P < 0.01) remained independently associated with events. Using a ROC curve analysis, LAD ≤ 69% and LAS ≤ 17% were the best cutoffs associated with an event.

CONCLUSION

In patients with moderate to severe AS, LAD and LAS are associated with LV dysfunction, AS severity, and are independently linked to events.

Predicting Outcomes in Patients With AsymptomaticModerate to Severe Aortic Stenosis

Outcomes in asymptomatic patients with aortic stenosis (AS) have been reported primarily from tertiary centers. Whether observations from a community hospital cohort would be similar or if clinical variables would assume a more important role remains uncertain. This retrospective cohort study from one community hospital followed asymptomatic patients with moderate to severe AS for 3 years following an index echocardiogram. Patients underwent standard echocardiographic imaging and assessment of AS severity. Outcomes included aortic valve replacement, onset of Class 4 heart failure and cardiovascular death. Inclusion or exclusion criteria were met by 190 patients (body mass index of 30.8 ± 7.5 kg/m² and age 70.9 ± 13.0 years). In this obese and racially diverse cohort, adverse outcomes occurred in 72 of 190 (38%), aortic valve replacement in 33 of 72 (46%), heart failure in 30 of 72 (42%), and cardiovascular death in 9 of 72 (13%). Univariate analyses found that the echocardiographic variables assessing AS severity (Vmax, mean aortic valve gradient, and the dimensionless index) were strongly associated with outcomes. A model predicting time to adverse outcomes included age, gender, Charlson index, Vmax, aortic valve area, the electrocardiographic variables of atrial fibrillation and left ventricular strain, and echocardiographic variables unrelated to the direct measurements of stenosis severity. In conclusion, direct echocardiographic measures of AS severity, echocardiographic parameters unrelated to AS severity plus the electrocardiographic variables of atrial fibrillation and left ventricular strain were the dominant predictors of adverse outcomes in a community hospital cohort of asymptomatic patients with moderate to severe AS.

The role and clinical implications of diastolic dysfunction in aortic stenosis

Diastolic dysfunction in aortic stenosis results primarily from left ventricular hypertrophy and myocardial fibrosis due to chronically elevated left ventricular systolic pressure. Currently, diastolic dysfunction does not have an explicit clinical role in management of patients with aortic stenosis. Studies have shown that improvement in diastolic dysfunction follows left ventricular remodelling after aortic valve replacement and that it occurs gradually or incompletely. Retrospective studies suggest that advanced grades of diastolic dysfunction at baseline are associated with increased mortality and adverse events even after aortic valve replacement. Recent studies have also associated myocardial fibrosis, a hallmark of diastolic dysfunction, with worse outcomes. In addition, these results were independent of the degree of aortic stenosis or valve replacement. Indirect evidence of the role of diastolic dysfunction in aortic stenosis also comes from paradoxical low-flow, low-gradient aortic stenosis, where disproportionate left ventricular hypertrophy leads to underfilling of the left ventricle, low-flow state and is associated with worse prognosis. Lastly, a limited number of studies suggest that worse diastolic dysfunction at baseline is detrimental in patients who develop aortic regurgitation after transcatheteraortic valve replacement, due to superimposition of volume overload on a stiff left ventricle. Current major limitations in our understanding of the prognostic role of diastolic dysfunction are the lack of universally accepted classification schemes, its dependence on dynamic loading conditions and the lack of larger prospective studies.

Diastolic mitral regurgitation following transcatheter aortic valve replacement: Incidence, predictors, and association with clinical outcomes

BACKGROUND

Diastolic mitral regurgitation (DMR) results from atrioventricular conduction disturbances, acute aortic regurgitation, and/or marked elevation of left ventricular filling pressure. Generally benign, in some clinical circumstances DMR has presumed to result in hemodynamic decompensation. The aforementioned causes of DMR are frequently encountered in patients treated by transcatheter aortic valve replacement (TAVR) but its clinical significance in this setting has not been studied. We sought to investigate the incidence of DMR and its prognostic implications following TAVR.

METHODS

Baseline clinical and echocardiographic variables from a prospective TAVR registry were analyzed to determine the correlates of post-procedural DMR and its impact on late outcomes (all-cause mortality and the composite of mortality and readmission due to heart failure).

RESULTS

Of 267 patients undergoing TAVR, post-procedural DMR was present in 25 (9.3%). Independent predictors of DMR included pacemaker implantation [OR=2.7 (95%CI 1.03-6.50)], post-procedural systolic MR and aortic regurgitation [OR=3.7 (1.20-10.80) and OR=4.1 (1.50-10.60), respectively], and use of self-expanding bioprostheses [OR=4.9 (1.60-21.0)]. The incidence of the combined endpoint of death and/or readmission for heart failure was higher in patients with versus those without DMR (25% vs. 41%, respectively, p=0.08), although this association did not attain statistical significance on multivariable analyses. Interaction term analysis indicated a trend toward a heightened risk for the composite endpoint among patients with post-procedural aortic regurgitation (≥moderate) in whom DMR occurred (χ² 2.94, p=0.09).

CONCLUSIONS

Although DMR following TAVR is common (occurring in approximately 1 of 10 patients), it is not independently associated with an increased risk of death and/or readmission for heart failure. Therefore, DMR post TAVR is more likely a marker of cardiac dysfunction than a causative factor.

Diastolic Function and Transcatheter Aortic Valve Replacement

BACKGROUND

Little is known about baseline diastolic dysfunction and changes in diastolic dysfunction grade after transcatheter aortic valve replacement (TAVR) for aortic stenosis (AS) and its impact on overall outcomes. The aim of this study was to describe baseline diastolic dysfunction and changes in diastolic dysfunction grade that occur with TAVR and their relationship to mortality and rehospitalization.

METHODS

This was a single-center study evaluating all TAVRs from January 2012 to June 2014. We compared parameters of diastolic dysfunction grade on pre-TAVR and 1 month post-TAVR echocardiograms for all patients undergoing the procedure. Descriptive statistics, Kaplan-Meier time-to-event analysis, and multivariate logistic regression were used.

RESULTS

Of a sample size of 120 patients undergoing TAVR for symptomatic severe AS, 90 were included in the final analysis after excluding significant mitral valve disease. There were improvements in individual parameters of diastolic dysfunction grade such as lateral e' velocity, E/lateral e', and left atrial volume index (nonsignificant trend) in the setting of improvement in aortic valve area and gradients and functional class pre- and post-TAVR. Multivariate analysis revealed that baseline diastolic dysfunction grade, but not post-TAVR or changes in diastolic dysfunction grade, was associated with 1-year death (hazard ratio, 1.163; 95% CI, 1.049-1.277, P = .005) and combined death/cardiovascular hospitalization (hazard ratio, 1.174; 95% CI, 1.032-1.318; P = .018).

CONCLUSIONS

In this single-center retrospective study of patients with symptomatic severe AS who underwent TAVR, several diastolic function parameters improved on echocardiography, but baseline diastolic dysfunction grade remained the most important echocardiographic factor associated with adverse 1-year outcomes.

Determinants and Prognostic Significance of Symptomatic Status in Patients with Moderately Dysfunctional Bicuspid Aortic Valves

Background

We aimed to identify the clinical and echocardiographic determinants of symptoms and their prognostic implications in patients with moderately dysfunctional bicuspid aortic valves (BAVs).

Methods

Among 1,019 subjects in the BAV registry treated in a single tertiary care center, the records of 127 patients (85 men, age 58±13 years) with moderately dysfunctional BAVs were comprehensively reviewed. The patients were divided into two groups based on symptom status: asymptomatic (n = 80) vs. symptomatic (n = 47). The primary end-point was defined as a composite of aortic valve surgery, hospitalization for heart failure, and any cause of death.

Results

The symptomatic group had a higher proportion of females, hypertension, aortic stenosis, and aortopathy than did the asymptomatic group. The symptomatic group showed lower e′ (5.5±1.7 vs. 6.5±2.2 cm/s, p = 0.003), higher E/e′ (13.3 ± 4.9 vs. 10.9±3.7, p = 0.002), and larger left atrial volume index (29.9±11.4 vs. 24.6±9.1 ml/m², p = 0.006) than did the asymptomatic group. In multivariate logistic regression analysis, female gender (odds ratio [OR] 2.84, 95% confidence interval [CI] 1.10–7.36, p = 0.031), hypertension (OR 3.07, 95% CI 1.20–7.82, p = 0.019), moderate aortic stenosis (OR 5.33 5.78, 95% CI 1.99–16.83, p = 0.001), E/e′ >15 (OR 3.82, 95% CI 1.03–11.19, p = 0.015), and aortopathy (OR 2.76, 95% CI 1.07–7.10, p = 0.035) were independently correlated with symptom status. The symptomatic group showed a significantly lower rate of event-free survival during the 8-year follow-up period (54±9% vs. 68±10%, p = 0.001).

Conclusions

In patients with moderately dysfunctional BAVs, the presence of moderate aortic stenosis, aortopathy, and diastolic dysfunction determines symptom status, along with female gender and hypertension. Symptom status was associated with clinical outcomes.

Combined use of tissue Doppler imaging and natriuretic peptides as prognostic marker in asymptomatic aortic stenosis

INTRODUCTION

Tissue Doppler imaging (TDI) and N-terminal-pro-Brain Natriuretic Peptide (NT-proBNP) provides useful non-invasive information about left ventricle filling pressures and both have demonstrated to be a prognostic marker in some valve disease as aortic stenosis (AS).

OBJECTIVES

To assess the clinical value of combined TDI and NT-proBNP information in asymptomatic AS patients.

MATERIAL AND METHODS

Prospective study of 350 initially asymptomatic moderate to severe AS patients with: Mean aortic valve area 0.8 (0.3) cm², mean gradient 45(13) mmHg, ejection fraction 61 (9) %. Mean age: 74.6 (4.3) years. In all patients were determined NT-proBNP in the serum and TDI parameters the lateral mitral annulus. We considered clinical event the admission in the hospital due to symptoms related to AS (angina, heart failure or syncope) as well as surgical treatment or mortality.

RESULTS

After a mean follow-up of 29 (10) months, 165 (47%) patients suffered some clinical event. In order to predict clinical events, Bootstrap analysis determined the best cut-point value: E/E' ratio higher than 13 and NT-proBNP higher than 515pg/mL. E/E' ratio provides more specificity (78.9% vs 55.9%) and NT-proBNP provides more sensitivity (76.6% vs 43.7%). Combined use of both parameters provides the best prognostic information (sensitivity 75.6%, specificity 67.2%, negative predictive value 82.1%, positive predictive value 57.5%, accuracy 71.4%).

CONCLUSION

Combined use of TDI and natriuretic peptides information provides incremental prognostic value and is a useful tool to predict the prognosis in asymptomatic AS patients.

Left ventricular stiffness predicts outcome in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation

OBJECTIVES

Assessment of the prognostic role of left ventricular stiffness (LVS) in patients with aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI).

METHODS

We performed a complete two-dimensional transthoracic echocardiographic study before and after TAVI in patients with severe AS at high surgical risk. In order to assess LVS, we measured LV end-diastolic pressure (EDP) invasively during TAVI and LV end-diastolic volume (EDV) by means of echocardiography. We defined LVS as the EDV indexed by body surface area at an EDP of 20 mm Hg (EDVI₂₀ ). Our aim was to assess the impact of LVS on one-year all-cause mortality after TAVI.

RESULTS

One hundred sixty-six patients undergoing TAVI (64% female; mean age 82.7 ± 5.1 years) were enrolled. Seven patients died within the first 30 days after TAVI and 21 within 1 year. Overall follow-up duration was 580 ± 478 days. At multivariate analysis, independent predictors of 1-year all-cause mortality were moderate-to-severe paravalvular leak (PVL; HR 4.7, 95% confidence interval [CI] 1.9-11, P=.0003), female gender (HR 3.5, 95% CI 1.0-12, P=.045), and EDVI₂₀ (HR 0.94, 95% CI 0.90-0.98, P=.015). In particular, patients with higher LVS (EDVI₂₀ ≤48 mL/m² ) had a 1-year mortality of 26.9% vs 7.4% in patients with lower LVS (EDVI₂₀ >48 mL/m² ; HR 4.2, 95% CI 1.6-10.6, P=.0007). Patients with higher LVS who developed moderate-to-severe PVL had the worst outcome (incremental chi-square test, P=.014).

CONCLUSION

In patients with AS, an increased LVS has a negative prognostic impact. Development of significant PVL in patients with higher LVS had an incremental adverse effect.

Prognostic Importance of Diastolic Dysfunction in Relation to Post Procedural Aortic Insufficiency in Patients Undergoing Transcatheter Aortic Valve Replacement

OBJECTIVES

We sought to examine whether baseline diastolic dysfunction (DD) is associated with increased mortality in patients who develop aortic insufficiency (AI) after transcatheter aortic valve replacement (TAVR).

BACKGROUND

Significant post-TAVR AI is associated with increased mortality, likely secondary to adverse hemodynamics secondary to volume overload and decreased LV compliance from chronic pressure overload. However, the effect of baseline DD on outcomes of patients with post-TAVR AI has not been studied.

METHODS

A total of 195 patients undergoing TAVR were included in the study. Patients with moderate-to-severe mitral stenosis, prior mitral valve replacement or atrial fibrillation were excluded. DD was classified at baseline by a 2-step approach as recommended by the American Society of Echocardiography while AI was evaluated 30 days post-TAVR. Follow up data up to 2 years post-TAVR was used in survival analysis.

RESULTS

Patients with severe baseline DD who developed ≥mild post-TAVR AI had increased mortality compared to all other patients (HR = 3.89, CI: 1.76-8.6, P = 0.001), which remained significant after adjusting for post-TAVR AI, pre-TAVR AI, baseline mitral regurgitation, ejection fraction, pulmonary artery pressure, creatinine clearance and history of stroke.

CONCLUSIONS

Even mild post-TAVR AI may have a negative impact on outcomes of patients with underlying severe DD. © 2016 Wiley Periodicals, Inc.

Calcific aortic stenosis

Calcific aortic stenosis (AS) is the most prevalent heart valve disorder in developed countries. It is characterized by progressive fibro-calcific remodelling and thickening of the aortic valve leaflets that, over years, evolve to cause severe obstruction to cardiac outflow. In developed countries, AS is the third-most frequent cardiovascular disease after coronary artery disease and systemic arterial hypertension, with a prevalence of 0.4% in the general population and 1.7% in the population >65 years old. Congenital abnormality (bicuspid valve) and older age are powerful risk factors for calcific AS. Metabolic syndrome and an elevated plasma level of lipoprotein(a) have also been associated with increased risk of calcific AS. The pathobiology of calcific AS is complex and involves genetic factors, lipoprotein deposition and oxidation, chronic inflammation, osteoblastic transition of cardiac valve interstitial cells and active leaflet calcification. Although no pharmacotherapy has proved to be effective in reducing the progression of AS, promising therapeutic targets include lipoprotein(a), the renin-angiotensin system, receptor activator of NF-κB ligand (RANKL; also known as TNFSF11) and ectonucleotidases. Currently, aortic valve replacement (AVR) remains the only effective treatment for severe AS. The diagnosis and staging of AS are based on the assessment of stenosis severity and left ventricular systolic function by Doppler echocardiography, and the presence of symptoms. The introduction of transcatheter AVR in the past decade has been a transformative therapeutic innovation for patients at high or prohibitive risk for surgical valve replacement, and this new technology might extend to lower-risk patients in the near future.

Echocardiographic determinants of LV functional improvement after transcatheter aortic valve replacement

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is an established therapy in high-risk patients with severe aortic stenosis. Among patients with reduced left ventricular ejection fraction (LVEF), it is unclear which patients will derive maximal benefit from TAVR.

METHODS

Clinical and echocardiographic data of patients with severe aortic stenosis and low LVEF (≤50%) who underwent TAVR at a single institution during 2009-2013 were retrospectively analyzed. Patients were divided into 2 groups post-TAVR based on improved LV function (Group A = ΔLVEF ≥ 10%) versus persistent LV dysfunction (Group B = ΔLVEF<10%). Echocardiographic parameters were assessed for their association with LVEF change post-TAVR. Kaplan-Meier analysis was performed to generate survival estimates.

RESULTS

Of 382 patients who underwent TAVR, 60 patients had low LVEF, LV function failed to improve ≥10% in 50% of patients following the procedure (Group B). At baseline echocardiograms, Group B had higher LVEF, stroke volume (SV), SV index; and lower E, E/E', and estimated pulmonary arterial systolic pressure (PASP) compared to Group A. Higher mortality was found in Group B compared to the Group A (p = 0.003) with a significantly shorter survival (Group A = 3.3 ± 0.1 years vs Group B = 2.7 ± 0.2 years, p = 0.003). One-year event free survival was 53.3% in Group B compared to 93.3% in Group A, with a stable trend over ensuing years (5-year survival; 53.3% versus 90.0%, p = 0.003).

CONCLUSIONS

In patients undergoing TAVR with depressed LV function, those who failed to improve were more likely to have relatively higher LVEF, SV, and SVI; and lower E, E/E', and PASP at baseline. Mortality rates were found to be higher in persistent LV dysfunction group. © 2015 Wiley Periodicals, Inc.

Relation between E/e' ratio and NT-proBNP levels in elderly patients with symptomatic severe aortic stenosis

BACKGROUND

Symptoms in the elderly patients with severe aortic stenosis (AS) and co-morbidities seem to lack in specificity. Therefore, objective parameters for increased left ventricular(LV) filling pressures are needed. The aim of this study was to investigate the correlation between the septal, lateral and average E/e' ratio and the value of the N-terminal pro-hormone of brain natriuretic peptide (NT-proBNP).

METHODS

Two-hundred-fifty consecutive symptomatic patients (mean age 80 ± 8 years, 52% men) with severe AS underwent transthoracic echocardiography and NT-proBNP measurement.

RESULTS

In the overall population the septal E/e' (r = 0,459, r(2) = 0,21, P <0,0001), lateral E/e' (r = 0,322, r(2) = 0,10, P <0,0001), and the average E/e' (r = 0,432, r(2) = 0,18, P <0,0001) were all significantly correlated to NT-proBNP. After the exclusion of patients with confounders (more than mild aortic or mitral regurgitation, severe renal dysfunction, obesity or severe COPD) the septal E/e' (r = 0,584, r(2) = 0,34, P <0,0001), lateral E/e' (r = 0,377, r(2) = 0,14, P <0,0001), and the average E/e' (r = 0,487, r(2) = 0,24, P <0,0001) were all significantly better correlated to NT-proBNP. In obese patients no significant correlations were seen. Previous bypass surgery did not alter the correlations.

CONCLUSIONS

In elderly patients with severe symptomatic AS there is a significant correlation between the E/e' ratio and NT-proBNP, in particular after exclusion of confounders. The correlation was best for the septal E/e' ratio and was preserved in patients with a history of bypass surgery.

The left ventricle in aortic stenosis--imaging assessment and clinical implications

Aortic stenosis has an increasing prevalence in the context of aging population. In these patients non-invasive imaging allows not only the grading of valve stenosis severity, but also the assessment of left ventricular function. These two goals play a key role in clinical decision-making. Although left ventricular ejection fraction is currently the only left ventricular function parameter that guides intervention, current imaging techniques are able to detect early changes in LV structure and function even in asymptomatic patients with significant aortic stenosis and preserved ejection fraction. Moreover, new imaging parameters emerged as predictors of disease progression in patients with aortic stenosis. Although proper standardization and confirmatory data from large prospective studies are needed, these novel parameters have the potential of becoming useful tools in guiding intervention in asymptomatic patients with aortic stenosis and stratify risk in symptomatic patients undergoing aortic valve replacement.

This review focuses on the mechanisms of transition from compensatory left ventricular hypertrophy to left ventricular dysfunction and heart failure in aortic stenosis and the role of non-invasive imaging assessment of the left ventricular geometry and function in these patients.

Causes of death and mortality and evaluation of prognostic factors in patients with severe aortic stenosis in an aging society

BACKGROUND

Severe aortic stenosis (AS) is now predominantly a disease of the elderly, with significant mortality and morbidity. In order to investigate the burden of severe AS in the current population, we assessed mortality, causes of death, clinical event rates, and prognostic factors of patients diagnosed with severe AS.

METHODS

A total of 519 consecutive patients (mean age, 78±9 years) with severe AS (aortic valve area <1.0 cm(2)) were retrospectively analyzed. All-cause mortality and clinical events including aortic valve replacement, heart failure requiring admission, acute coronary syndrome, and syncope were measured as main outcome.

RESULTS

During a median follow-up of 3.5 years, 167 patients (32%) died. Overall survival rates at 1 and 3 years were 86% and 70%, respectively. Of all deaths, 101 (61%) were cardiovascular-related and 56 (33%) were non-cardiovascular. Syncope occurred in only 18 (4%) patients, while heart failure requiring admission occurred in 188 (43%) patients as the most frequent event. Male, severe symptoms (New York Heart Association functional class, III/IV), inactive state, previous history of heart failure, renal insufficiency, hemodialysis treatment, peripheral vascular disease, malignancy, and statin use at enrollment were significantly and independently associated with death among the patients.

CONCLUSIONS

Among the one-third of severe AS patients who died during follow-up, 61% of deaths were cardiovascular-related. Cardiovascular death may be the leading, but not the only, cause of death for contemporary severe AS patients. Factors such as severe symptomatic status, lower daily activity level, and chronic kidney diseases were strong predictive factors of worse survival in this population.

Echo Doppler Estimation of Pulmonary Capillary Wedge Pressure in Patients with Severe Aortic Stenosis

BACKGROUND

Transcatheter aortic valve replacement (TAVR) has become a treatment option for patients with severe aortic stenosis (AS) and high surgical risk. Assessment of symptoms in these patients is challenging because of advanced age, comorbidities, and limited physical activity. Noninvasive quantification of pulmonary capillary wedge pressure (PCWP) in candidates for TAVR may be helpful for risk stratification. The objective of the study was to create a model for estimation of PCWP by echo Doppler in patients with severe AS.

METHODS AND RESULTS

Data from 80 patients with severe AS referred for TAVR were used to develop an echo Doppler model for predicting PCWP. Its performance was evaluated in the test cohort of 33 patients who had invasive and noninvasive evaluation. No single echo Doppler parameter estimated PCWP accurately. In the retrospective analysis, the multilinear regression provided an accurate estimate of PCWP (r(2) = 0.74). The model included, in order of importance (all P < 0.05), the ratio of early transmitral velocity (E) to annular velocity (E'), the left ventricular ejection fraction, and the velocity time integral of tricuspid regurgitation signal. In the prospective cohort of patients with severe AS, the model demonstrated good predictive ability of PCWP (r = 0.77, P < 0.01).

CONCLUSION

In patients with severe AS, noninvasive estimation of PCWP is possible by integration of two-dimensional, spectral, and tissue Doppler variables.

Echocardiographic guidance for diagnostic and therapeutic percutaneous procedures

Echocardiographic guidance has an important role in percutaneous cardiovascular procedures and vascular access. The advantages include real time imaging, portability, and availability, which make it an effective imaging modality. This article will review the role of echocardiographic guidance for diagnostic and therapeutic percutaneous procedures, specifically, transvenous and transarterial access, pericardiocentesis, endomyocardial biopsy, transcatheter pulmonary valve replacement, pulmonary valve repair, transcatheter aortic valve implantation, and percutaneous mitral valve repair. We will address the ways in which echocardiographic guidance provides these procedures with detailed information on anatomy, adjacent structures, and intraprocedural instrument position, thus resulting in improvement in procedural efficacy, safety and patient outcomes.

The syndrome of degenerative calcific aortic stenosis: prevalence of multiple pathophysiologic disorders in association with valvular stenosis and their implications

BACKGROUND

We hypothesized that degenerative calcific aortic stenosis (DCAS) is a syndrome influenced by factors beyond aortic valve stenosis (AS). The aim of this study was to assess how frequently DCAS is complicated by increased vascular load, systolic and/or diastolic left ventricular (LV) dysfunction, and comorbid disorders.

METHODS

In 215 consecutive patients > 60 years of age with severe and moderate AS, we analyzed systemic arterial compliance, global hemodynamic load, LV ejection fraction (EF), the presence of diastolic dysfunction, and other valvular or systemic disorders.

RESULTS

A total of 164 patients had severe AS and 51 had moderate AS. In patients with severe AS, the prevalence of increased vascular load was 42%; LV systolic and diastolic dysfunction was present in 27% and 42%; other valve diseases in 23%; and comorbid disorders in 82%. In the moderate AS group, abnormal vascular load was found in 52%; LV systolic and diastolic dysfunction was prevalent in 26% and 31%; other valve diseases in 17%; and comorbid disorders in 78% patients. More than half the patients in both groups had symptoms. In both severe and moderate AS groups, the prevalence of increased vascular load and systolic dysfunction was higher in the symptomatic group.

CONCLUSION

Considerable number of patients with DCAS have abnormal vascular load, abnormal LV function, and significant coexisting disorders. These could influence the total pathophysiologic burden on the heart and symptom expression. Thus, DCAS should not be considered just as valvular stenosis, but a syndrome of DCAS because of the diagnostic, prognostic, and therapeutic implications of various factors associated with it.

Echocardiography in transcatheter aortic valve implantation and mitral valve clip

Transcatheter aortic valve implantation and transcatheter mitral valve repair (MitraClip) procedures have been performed worldwide. In this paper, we review the use of two-dimensional and three-dimensional transesophageal echo for guiding transcatheter aortic valve replacement and mitral valve repair.

Outcomes and survival with aortic valve replacement compared with medical therapy in patients with low-, moderate-, and severe-gradient severe aortic stenosis and normal left ventricular ejection fraction

BACKGROUND

This study determined outcomes and survival with aortic valve replacement (AVR) versus medical therapy in patients with normal left ventricular ejection fraction (LVEF) with severely reduced aortic valve areas (AVA) but nonsevere mean gradients.

METHODS

We identified 248 aortic stenosis (AS) patients with LVEF ≥ 50% and echocardiographic AVA < 1.0 cm(2). Group 1 had low-gradient: <30 mmHg mean gradient; group 2 (moderate: 30 to 40 mm Hg); and group 3 (severe: >40 mm).

RESULTS

There were 94, 87, and 67 patients in groups 1, 2, and 3. Incidence of death in groups 1, 2, and 3 were 55%, 39%, and 39% (P not significant). Incidence of AVR in groups 1, 2, and 3 were 23%, 53%, and 49% (P < 0.0001 for group 1 vs. 2; P = 0.0003 for group 1 vs. group 3). Incidence of AVR or death was 71%, 77%, and 76% (P not significant). AVR (hazard ratio = 0.30; 95% CI, 0.18, 0.51; P < 0.0001) and mitral annular calcification (hazard ratio = 2.33; 95% CI, 1.40, 3.88; P = 0.001) were independently associated with time to mortality. Kaplan-Meier curves for time to death did not differ significantly among the three groups. Kaplan-Meier survival curves for patients with and without AVR showed patients in all three groups who underwent AVR had significantly greater survival.

CONCLUSION

Among patients with normal LVEF and AVA < 1.0 cm(2), overall survival does not differ among those with low-, moderate-, or severe-aortic valve gradients. Survival is significantly improved with AVR, regardless of gradient.