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Ngiam JN, Chew N, Jou E, Ho JS, Pramotedham T, Liong TS, Kuntjoro I, Yeo TC, Sia CH, Kong WKF, Poh KK. Increased left ventricular remodelling index in paradoxical low-flow severe aortic stenosis with preserved left ventricular ejection fraction compared to normal-flow severe aortic stenosis. Singapore Med J 2024:00077293-990000000-00094. [PMID: 38363650 DOI: 10.4103/singaporemedj.smj-2022-107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 08/01/2022] [Indexed: 02/18/2024]
Abstract
INTRODUCTION Patients with paradoxical low-flow (LF) severe aortic stenosis (AS) despite preserved left ventricular ejection fraction (LVEF) appear distinct from normal-flow (NF) patients, showing worse prognosis, more concentric hypertrophy and smaller left ventricular (LV) cavities. The left ventricular remodelling index (LVRI) has been demonstrated to reliably discriminate between physiologically adapted athlete's heart and pathological LV remodelling. METHODS We studied patients with index echocardiographic diagnosis of severe AS (aortic valve area <1 cm2) with preserved LVEF (>50%). The LVRI was determined by the ratio of the LV mass to the end-diastolic volume, as previously reported, and was compared between patients with LF and NF AS. Patients were prospectively followed up for at least 3 years, and clinical outcomes were examined in association with LVRI. RESULTS Of the 450 patients studied, 112 (24.9%) had LF AS. While there were no significant differences in baseline clinical profile between LF and NF patients, LVRI was significantly higher in the LF group. Patients with high LVRI (>1.56 g/mL) had increased all-cause mortality (log-rank 9.18, P = 0.002) and were more likely to be admitted for cardiac failure (log-rank 7.61, P = 0.006) or undergo aortic valve replacement (log-rank 18.4, P < 0.001). After adjusting for the effect of age, hypertension, aortic valve area and mean pressure gradient on multivariate Cox regression, high LVRI remained independently associated with poor clinical outcomes (hazard ratio 1.64, 95% confidence interval 1.19-2.25, P = 0.002). CONCLUSION Pathological LV remodelling (increased LVRI) was more common in patients with LF AS, and increased LVRI independently predicts worse clinical outcomes.
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Affiliation(s)
| | - Nicholas Chew
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - Eric Jou
- MRC Laboratory of Molecular Biology, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Jamie Sy Ho
- Academic Foundation Programme, Royal Free London NHS Foundation Trust, London, United Kingdom
| | | | - Tze Sian Liong
- Department of Medicine, National University Health System, Singapore
| | - Ivandito Kuntjoro
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - Tiong-Cheng Yeo
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - William Kok Fai Kong
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kian-Keong Poh
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Velders BJJ, Groenwold RHH, Ajmone Marsan N, Kappetein AP, Wijngaarden RAFDLV, Braun J, Klautz RJM, Vriesendorp MD. Improving accuracy in diagnosing aortic stenosis severity: An in-depth analysis of echocardiographic measurement error through literature review and simulation study. Echocardiography 2023; 40:892-902. [PMID: 37519290 DOI: 10.1111/echo.15664] [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: 04/26/2023] [Revised: 07/10/2023] [Accepted: 07/23/2023] [Indexed: 08/01/2023] Open
Abstract
AIMS The present guidelines advise replacing the aortic valve for individuals with severe aortic stenosis (AS) based on various echocardiographic parameters. Accurate measurements are essential to avoid misclassification and unnecessary interventions. The objective of this study was to evaluate the influence of measurement error on the echocardiographic evaluation of the severity of AS. METHODS AND RESULTS A systematic review was performed to examine whether measurement errors are reported in studies focusing on the prognostic value of peak aortic jet velocity (Vmax ), mean pressure gradient (MPG), and effective orifice area (EOA) in asymptomatic patients with AS. Out of the 37 studies reviewed, 17 (46%) acknowledged the existence of measurement errors, but none of them utilized methods to address them. Secondly, the magnitude of potential errors was collected from available literature for use in clinical simulations. Interobserver variability ranged between 0.9% and 8.3% for Vmax and MPG but was higher for EOA (range 7.7%-12.7%), indicating lower reliability. Assuming a circular left ventricular outflow tract area led to a median underestimation of EOA by 23% compared to planimetry by other modalities. A clinical simulation resulted in the reclassification of 42% of patients, shifting them from a diagnosis of severe AS to moderate AS. CONCLUSIONS Measurement errors are underreported in studies on echocardiographic assessment of AS severity. These errors can lead to misclassification and misdiagnosis. Clinicians and scientists should be aware of the implications for accurate clinical decision-making and assuring research validity.
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Affiliation(s)
- Bart J J Velders
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Biomedical Data Science, Leiden University Medical Center, Leiden, The Netherlands
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Arie-Pieter Kappetein
- Global Clinical Operations, Coronary and Structural Heart, Medtronic, Maastricht, The Netherlands
| | | | - Jerry Braun
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Robert J M Klautz
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Michiel D Vriesendorp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
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Manzo R, Ilardi F, Nappa D, Mariani A, Angellotti D, Immobile Molaro M, Sgherzi G, Castiello DS, Simonetti F, Santoro C, Canonico ME, Avvedimento M, Piccolo R, Franzone A, Esposito G. Echocardiographic Evaluation of Aortic Stenosis: A Comprehensive Review. Diagnostics (Basel) 2023; 13:2527. [PMID: 37568890 PMCID: PMC10417789 DOI: 10.3390/diagnostics13152527] [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: 06/26/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
Echocardiography represents the most important diagnostic tool in the evaluation of aortic stenosis. The echocardiographic assessment of its severity should always be performed through a standardized and stepwise approach in order to achieve a comprehensive evaluation. The latest technical innovations in the field of echocardiography have improved diagnostic accuracy, guaranteeing a better and more detailed evaluation of aortic valve anatomy. An early diagnosis is of utmost importance since it shortens treatment delays and improves patient outcomes. Echocardiography plays a key role also in the evaluation of all the structural changes related to aortic stenosis. Detailed evaluation of subtle and subclinical changes in left ventricle function has a prognostic significance: scientific efforts have been addressed to identify the most accurate global longitudinal strain cut-off value able to predict adverse outcomes. Moreover, in recent years the role of artificial intelligence is increasingly emerging as a promising tool able to assist cardiologists in aortic stenosis screening and diagnosis, especially by reducing the rate of aortic stenosis misdiagnosis.
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Affiliation(s)
| | - Federica Ilardi
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, 80131 Naples, Italy
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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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Minamino-Muta E, Kato T, Morimoto T, Taniguchi T, Ando K, Kanamori N, Murata K, Kitai T, Kawase Y, Miyake M, Izumi C, Mitsuoka H, Kato M, Hirano Y, Matsuda S, Nagao K, Murakami T, Takeuchi Y, Yamane K, Toyofuku M, Ishii M, Inoko M, Ikeda T, Ishii K, Hotta K, Jinnai T, Kato Y, Inuzuka Y, Maeda C, Morikami Y, Saito N, Minatoya K, Kimura T. A risk prediction model in asymptomatic patients with severe aortic stenosis: CURRENT-AS risk score. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 6:166-174. [PMID: 31386103 DOI: 10.1093/ehjqcco/qcz044] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/26/2019] [Accepted: 08/05/2019] [Indexed: 02/06/2023]
Abstract
AIMS Early aortic valve replacement (AVR) might be beneficial in selected high-risk asymptomatic patients with severe aortic stenosis (AS), considering their poor prognosis when managed conservatively. This study aimed to develop and validate a clinical scoring system to predict AS-related events within 1 year after diagnosis in asymptomatic severe AS patients. METHODS AND RESULTS We analysed 1274 asymptomatic severe AS patients derived from a retrospective multicentre registry enrolling consecutive patients with severe AS in Japan (CURRENT AS registry), who were managed conservatively and completed 1-year follow-up without AVR. From a randomly assigned derivation set (N = 849), we developed CURRENT AS risk score for the AS-related event (a composite of AS-related death and heart failure hospitalization) within 1 year using a multivariable logistic regression model. The risk score comprised independent risk predictors including left ventricular ejection fraction <60%, haemoglobin ≤11.0 g/dL, chronic lung disease (2 points), diabetes mellitus, haemodialysis, and any concomitant valve disease (1 point). The predictive accuracy of the model was good with the area under the curve of 0.79 and 0.77 in the derivation and validation sets (N = 425). In the validation set, the 1-year incidence of AS-related events was much higher in patients with score ≥2 than in patients with score ≤1 (Score 0: 2.2%, Score 1: 1.9%, Score 2: 13.4%, Score 3: 14.3%, and Score ≥4: 22.7%, P < 0.001). CONCLUSION The CURRENT-AS risk score integrating clinical and echocardiographic factors well-predicted the risk of AS-related events at 1 year in asymptomatic patients with severe AS and was validated internally.
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Affiliation(s)
- Eri Minamino-Muta
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Takao Kato
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo 663-8501, Japan
| | - Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, 3-2-1 Asano, Kokurakita-ku, Kokura, Fukuoka 802-8555, Japan
| | - Norio Kanamori
- Division of Cardiology, Shimada Municipal Hospital, 1200-5 Noda, Shimada, Shizuoka 427-8502, Japan
| | - Koichiro Murata
- Department of Cardiology, Shizuoka City Shizuoka Hospital, 10-93 Otemachi, Aoi-ku, Shizuoka 420-8630, Japan
| | - Takeshi Kitai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojimaminamimachi, Chuo-ku, Kobe-City, Hyogo 650-0047, Japan
| | - Yuichi Kawase
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama 710-8602, Japan
| | - Makoto Miyake
- Department of Cardiology, Tenri Hospital, Tenri, Japan
| | - Chisato Izumi
- Division of Heart Failure, National Cerebral and Cardiovascular Center, 200 Mishima-cho, Tenri, Nara 632-8555, Japan
| | - Hirokazu Mitsuoka
- Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine, 1248-1 Otoda-cho, Ikoma, Nara 630-0293, Japan
| | - Masashi Kato
- Department of Cardiology, Mitsubishi Kyoto Hospital, 1 Katsuragosho-cho, Nishigyo-ku, Kyoto 615-8087, Japan
| | - Yutaka Hirano
- Department of Cardiology, Kinki University Hospital, 377-2 Ohno-higashi, Sayama, Osaka 589-8511, Japan
| | - Shintaro Matsuda
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Kazuya Nagao
- Department of Cardiovascular Center, Osaka Red Cross Hospital, 5-30 Hudegasaki, Tennoji-Ku, Osaka 543-8555, Japan
| | - Tomoyuki Murakami
- Department of Cardiology, Koto Memorial Hospital, 2-1 Hiramatsu-cho, Higashioumi, Shiga 527-0134, Japan
| | - Yasuyo Takeuchi
- Department of Cardiology, Shizuoka General Hospital, 4-27-1 Kitaando-cho, Aoi-ku, Shizuoka 420-8257, Japan
| | - Keiichiro Yamane
- Department of Cardiology, Nishikobe Medical Center, 5-7-1 Kojida-, Nishi-ku, Kobe 651-2273, Japan
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, 4-20 Komatsubara-dori, Wakayama 640-8558, Japan
| | - Mitsuru Ishii
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1 Fukakusamukaihata-cho, Fushimi-ku, Kyoto 612-8555, Japan
| | - Moriaki Inoko
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, 2-4-20 Ohgimachi, Kita-ku, Osaka 530-8480, Japan
| | - Tomoyuki Ikeda
- Department of Cardiology, Hikone Municipal Hospital, 1882 Yasaka-cho, Hikone, Shiga 522-8539, Japan
| | - Katsuhisa Ishii
- Department of Cardiology, Kansai Electric Power Hospital, 2-1-7 Fukushima, Fukushima-ku, Osaka 553-0003, Japan
| | - Kozo Hotta
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77 Higashi-naniwa-cho, Amagasaki, Hyogo 660-8550, Japan
| | - Toshikazu Jinnai
- Department of Cardiology, Japanese Red Cross Otsu Hospital, 1-1-35 Nagara, Otsu, Shiga 520-0046, Japan
| | - Yoshihiro Kato
- Department of Cardiology, Saiseikai Noe Hospital, 1-3-25 Furuichi, Joto-ku, Osaka 536-0001, Japan
| | - Yasutaka Inuzuka
- Department of Cardiology, Shiga Medical Center for Adults, 5-4-3 Moriyama, Moriyama, Shiga 524-8524, Japan
| | - Chiyo Maeda
- Department of Cardiology, Hamamatsu Rosai Hospital, 25 Shogen-cho, Higashi-ku, Hamamatsu, Shizuoka 430-8525, Japan
| | - Yuko Morikami
- Department of Cardiology, Hirakata Kohsai Hospital, 1-2-2-1 Hujisakahigashi-cho, Hirakata, Osaka 573-0153, Japan
| | - Naritatsu Saito
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
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Ando T, Onishi T, Tobaru T. Extremely severe aortic stenosis - Is TAVR the answer? Int J Cardiol 2021; 331:69-70. [PMID: 33516845 DOI: 10.1016/j.ijcard.2021.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 01/13/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Tomo Ando
- Kawasaki Saiwai Hospital, Department of Cardiology, Kawasaki City, Kanagawa, Japan.
| | - Takayuki Onishi
- Kawasaki Saiwai Hospital, Department of Cardiology, Kawasaki City, Kanagawa, Japan
| | - Tetsuya Tobaru
- Kawasaki Saiwai Hospital, Department of Cardiology, Kawasaki City, Kanagawa, Japan
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7
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Taniguchi T, Morimoto T, Takeji Y, Kato T, Kimura T. Contemporary issues in severe aortic stenosis: review of current and future strategies from the Contemporary Outcomes after Surgery and Medical Treatment in Patients with Severe Aortic Stenosis registry. Heart 2020; 106:802-809. [PMID: 32114519 DOI: 10.1136/heartjnl-2019-315672] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/10/2020] [Accepted: 01/13/2020] [Indexed: 02/07/2023] Open
Abstract
Contemporary Outcomes after Surgery and Medical Treatment in Patients with Severe Aortic Stenosis (CURRENT AS) registry was a large Japanese multicentre retrospective registry of consecutive patients with severe aortic stenosis (AS) before introduction of transcatheter aortic valve implantation. We sought to overview the data from the CURRENT AS registry to discuss the three major contemporary issues related to clinical practice in patients with severe AS: (1) under-referral/underuse of surgical aortic valve replacement (SAVR) in symptomatic patients with severe AS, (2) management of asymptomatic patients with severe AS and (3) management of patients with low-gradient severe aortic stenosis (LG-AS). First, despite the dismal prognosis of symptomatic patients with severe AS, SAVR, including those performed during follow-up, was reported to be underused. In the CURRENT AS registry, overall 53% of symptomatic patients underwent aortic valve replacement (AVR) during follow-up. Second, we reported that compared with conservative strategy, initial AVR strategy was associated with lower risk of all-cause death and heart failure hospitalisation in asymptomatic patients with severe AS. Although current recommendations for AVR are mainly dependent on the patient symptoms, some patients may not complain of any symptom because of their sedentary lifestyle. We also reported several important objective factors associated with worse clinical outcomes in asymptomatic patients with severe AS for risk stratification. Finally, initial AVR strategy was associated with better long-term clinical outcomes than conservative strategy in both patients with high-gradient AS and patients with LG-AS. The favourable effect of initial AVR strategy was also seen in patients with LG-AS with left ventricular ejection fraction of ≥50%.
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Affiliation(s)
- Tomohiko Taniguchi
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.,Department of Cardiovascular Medicine, Faculty of Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yasuaki Takeji
- Department of Cardiovascular Medicine, Faculty of Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takao Kato
- Department of Cardiovascular Medicine, Faculty of Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Faculty of Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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8
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Kanamori N, Taniguchi T, Morimoto T, Watanabe H, Shiomi H, Ando K, Murata K, Kitai T, Kawase Y, Izumi C, Miyake M, Mitsuoka H, Kato M, Hirano Y, Matsuda S, Nagao K, Inada T, Mabuchi H, Takeuchi Y, Yamane K, Toyofuku M, Ishii M, Minamino-Muta E, Kato T, Inoko M, Ikeda T, Komasa A, Ishii K, Hotta K, Higashitani N, Kato Y, Inuzuka Y, Maeda C, Jinnai T, Morikami Y, Saito N, Minatoya K, Aoyama T, Kimura T. Prognostic Impact of Aortic Valve Area in Conservatively Managed Patients With Asymptomatic Severe Aortic Stenosis With Preserved Ejection Fraction. J Am Heart Assoc 2020; 8:e010198. [PMID: 30712486 PMCID: PMC6405588 DOI: 10.1161/jaha.118.010198] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Data are scarce on the role of aortic valve area (AVA) to identify those patients with asymptomatic severe aortic stenosis (AS) who are at high risk of adverse events. We sought to explore the prognostic impact of AVA in asymptomatic patients with severe AS in a large observational database. Methods and Results Among 3815 consecutive patients with severe AS enrolled in the CURRENT AS (Contemporary Outcomes After Surgery and Medical Treatment in Patients With Severe Aortic Stenosis) registry, the present study included 1309 conservatively managed asymptomatic patients with left ventricular ejection fraction ≥50%. The study patients were subdivided into 3 groups based on AVA (group 1: AVA >0.80 cm2, N=645; group 2: 0.8 cm2 ≥AVA >0.6 cm2, N=465; and group 3: AVA ≤0.6 cm2, N=199). The prevalence of very severe AS patients (peak aortic jet velocity ≥5 m/s or mean aortic pressure gradient ≥60 mm Hg) was 2.0%, 5.8%, and 26.1% in groups 1, 2, and 3, respectively. The cumulative 5‐year incidence of AVR was not different across the 3 groups (39.7%, 43.7%, and 39.9%; P=0.43). The cumulative 5‐year incidence of the primary outcome measure (a composite of aortic valve–related death or heart failure hospitalization) was incrementally higher with decreasing AVA (24.1%, 29.1%, and 48.1%; P<0.001). After adjusting for confounders, the excess risk of group 3 and group 2 relative to group 1 for the primary outcome measure remained significant (hazard ratio, 2.21, 95% CI, 1.56–3.11, P<0.001; and hazard ratio, 1.34, 95% CI, 1.01–1.78, P=0.04, respectively). Conclusions AVA ≤0.6 cm2 would be a useful marker to identify those high‐risk patients with asymptomatic severe AS, who might benefit from early AVR. Clinical Trial Registration URL: www.umin.ac.jp. Unique identifier: UMIN000012140. See Editorial by Tribouilloy et al
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Kanamori N, Taniguchi T, Morimoto T, Shiomi H, Ando K, Murata K, Kitai T, Kawase Y, Izumi C, Miyake M, Mitsuoka H, Kato M, Hirano Y, Matsuda S, Nagao K, Inada T, Mabuchi H, Takeuchi Y, Yamane K, Toyofuku M, Ishii M, Minamino-Muta E, Kato T, Inoko M, Ikeda T, Komasa A, Ishii K, Hotta K, Higashitani N, Kato Y, Inuzuka Y, Maeda C, Jinnai T, Morikami Y, Saito N, Minatoya K, Aoyama T, Kimura T. Asymptomatic versus Symptomatic Patients with Severe Aortic Stenosis. Sci Rep 2018; 8:10080. [PMID: 29973671 PMCID: PMC6031663 DOI: 10.1038/s41598-018-28162-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 06/13/2018] [Indexed: 01/19/2023] Open
Abstract
It is unknown how much different are the clinical outcomes between asymptomatic and symptomatic patients with severe aortic stenosis (AS). In the CURRENT AS registry enrolling 3,815 consecutive patients with severe AS, we compared the long-term outcomes between 1808 asymptomatic and 1215 symptomatic patients (exertional dyspnea: N = 813, syncope: N = 136, and angina: N = 266) without heart failure (HF) hospitalization. Symptomatic patients had greater AS severity, and more depressed left ventricular function than asymptomatic patients without much difference in other baseline characteristics. During a median follow-up of 3.2 years, aortic valve replacement (AVR) was performed in 62% of symptomatic patients, and 38% of asymptomatic patients. The cumulative 5-year incidences for the primary outcome measure (a composite of aortic valve-related death or HF hospitalization) was higher in symptomatic patients than in asymptomatic patients (32.3% versus 27.6%, P < 0.001). After adjusting for AVR and other variables, the greater risk of symptomatic relative to asymptomatic patients for the primary outcome measure was significant (hazard ratio 1.64, 95% confidence interval 1.41-1.96, P < 0.001). In conclusions, the excess risk of symptomatic relative to asymptomatic patients with severe AS for the aortic valve-related event was significant. However, the prevalence of AVR in symptomatic patients was not optimal.
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Affiliation(s)
- Norio Kanamori
- Division of Cardiology, Shimada Municipal Hospital, Shimada, Japan
| | - Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, 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
| | - Koichiro Murata
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Takeshi Kitai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yuichi Kawase
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Chisato Izumi
- Department of Cardiology, Tenri Hospital, Tenri, Japan
| | - Makoto Miyake
- Department of Cardiology, Tenri Hospital, Tenri, Japan
| | - Hirokazu Mitsuoka
- Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine, Ikoma, Japan
| | - Masashi Kato
- Department of Cardiology, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Yutaka Hirano
- Department of Cardiology, Kinki University Hospital, Osakasayama, Japan
| | - Shintaro Matsuda
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, 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
| | | | - 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
| | - Eri Minamino-Muta
- 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
| | - 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 Cardiology, Kansai Electric Power Hospital, Osaka, 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
| | | | - Yoshihiro Kato
- Department of Cardiology, Saiseikai Noe Hospital, Osaka, Japan
| | - Yasutaka Inuzuka
- Department of Cardiology, Shiga Medical Center for Adults, Moriyama, Japan
| | - Chiyo Maeda
- Department of Cardiology, Hamamatsu Rosai Hospital, Hamamatsu, Japan
| | - Toshikazu Jinnai
- Department of Cardiology, Japanese Red Cross Otsu Hospital, Otsu, 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 Aoyama
- Division of Cardiology, Shimada Municipal Hospital, Shimada, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
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