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Abdelfattah OM, Jacquemyn X, Kapadia SR, Van Meighem N, Clavel MA, Généreux P, Leon M, Pibarot P. Early Aortic Valve Replacement in Moderate Aortic Stenosis. JACC. ADVANCES 2024; 3:101190. [PMID: 39253710 PMCID: PMC11381792 DOI: 10.1016/j.jacadv.2024.101190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Affiliation(s)
| | | | - Samir R Kapadia
- Heart, Thoracic and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Marie-Annick Clavel
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Philippe Généreux
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA
| | - Martin Leon
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
- NewYork-Presbyterian Hospital/Columbia University, Medical Center, New York, New York, USA
| | - Philippe Pibarot
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
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Caprio MV, De Donno F, Bisaccia G, Mantini C, Di Baldassarre A, Gallina S, Khanji MY, Ricci F. Moderate aortic stenosis: Navigating the uncharted. Echocardiography 2024; 41:e15859. [PMID: 38853624 DOI: 10.1111/echo.15859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 05/18/2024] [Accepted: 05/25/2024] [Indexed: 06/11/2024] Open
Abstract
Aortic stenosis (AS) stands as the most common valvular heart disease in developed countries and is characterized by progressive narrowing of the aortic valve orifice resulting in elevated transvalvular flow resistance, left ventricular hypertrophy, and progressive increased risk of heart failure and sudden death. This narrative review explores clinical challenges and evolving perspectives in moderate AS, where discrepancies between aortic valve area and pressure gradient measurements may pose diagnostic and therapeutic quandaries. Transthoracic echocardiography is the first-line imaging modality for AS evaluation, yet cases of discordance may require the application of ancillary noninvasive diagnostic modalities. This review underscores the importance of accurate grading of AS severity, especially in low-gradient phenotypes, emphasizing the need for vigilant follow-up. Current clinical guidelines primarily recommend aortic valve replacement for severe AS, potentially overlooking latent risks in moderate disease stages. The noninvasive multimodality imaging approach-including echocardiography, cardiac magnetic resonance, computed tomography, and nuclear techniques-provides unique insights into adaptive and maladaptive cardiac remodeling in AS and offers a promising avenue to deliver precise indications and exact timing for intervention in moderate AS phenotypes and asymptomatic patients, potentially improving long-term outcomes. Nevertheless, what we may have gleaned from a large amount of observational data is still insufficient to build a robust framework for clinical decision-making in moderate AS. Future research will prioritize randomized clinical trials designed to weigh the benefits and risks of preemptive aortic valve replacement in the management of moderate AS, as directed by specific imaging and nonimaging biomarkers.
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Affiliation(s)
- Maria Vittoria Caprio
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
- SS Annunziata Polyclinic University Hospital, University Cardiology Division, Chieti, Italy
| | - Federica De Donno
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
- SS Annunziata Polyclinic University Hospital, University Cardiology Division, Chieti, Italy
| | - Giandomenico Bisaccia
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Cesare Mantini
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Angela Di Baldassarre
- Department of Medicine and Aging Sciences, and Reprogramming and Cell Differentiation Lab, Center for Advanced Studies and Technology (CAST), G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Sabina Gallina
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
- SS Annunziata Polyclinic University Hospital, University Cardiology Division, Chieti, Italy
| | - Mohammed Y Khanji
- Newham University Hospital, Barts Health NHS Trust, Plaistow, London, UK
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
- NIHR Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary University, London, UK
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
- SS Annunziata Polyclinic University Hospital, University Cardiology Division, Chieti, Italy
- Department of Clinical Sciences, Lund University, Malmö, Sweden
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Hariri EH, Badwan O, Kassab J, Layoun H, Skoza W, Burton R, Harb SC, Puri R, Reed GW, Krishnaswamy A, Svensson LG, Kapadia S. Role of aortic valve replacement in moderate aortic stenosis: a 10-year outcomes study. Open Heart 2024; 11:e002616. [PMID: 38769066 PMCID: PMC11110558 DOI: 10.1136/openhrt-2024-002616] [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: 01/25/2024] [Accepted: 03/12/2024] [Indexed: 05/22/2024] Open
Abstract
OBJECTIVE Patients with moderate aortic stenosis (AS) exhibit high morbidity and mortality. Limited evidence exists on the role of aortic valve replacement (AVR) in this patient population. To investigate the benefit of AVR in moderate AS on survival and left ventricular function. METHODS In a retrospective cohort study, patients with moderate AS between 2008 and 2016 were selected from the Cleveland Clinic echocardiography database and followed until 2018. Patients were classified as receiving AVR or managed medically (clinical surveillance). All-cause and cardiovascular mortality were assessed by survival analyses. Temporal haemodynamic and structural changes were assessed with longitudinal analyses using linear mixed effects models. RESULTS We included 1421 patients (mean age, 75.3±5.4 years and 39.9% women) followed over a median duration of 6 years. Patients in the AVR group had lower risk of all-cause (adjusted HR (aHR)=0.51, 95% CI: 0.34 to 0.77; p=0.001) and cardiovascular mortality (aHR=0.50, 95% CI: 0.31 to 0.80; p=0.004) compared with those in the clinical surveillance group irrespective of sex, receipt of other open-heart surgeries and underlying malignancy. These findings were seen only in those with preserved left ventricular ejection fraction (LVEF) ≥50%. Further, patients in the AVR group had a significant trend towards an increase in LVEF and a decrease in right ventricular systolic pressure compared with those in the clinical surveillance group. CONCLUSIONS In patients with moderate AS, AVR was associated with favourable clinical outcomes and left ventricular remodelling.
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Affiliation(s)
- Essa H Hariri
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Osamah Badwan
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Joseph Kassab
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Habib Layoun
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Warren Skoza
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Robert Burton
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Serge C Harb
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rishi Puri
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Grant W Reed
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amar Krishnaswamy
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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Nguyen D, Marwick T, Moodie M, Gao L. Early offering transcatheter aortic valve replacement to patients with moderate aortic stenosis: quantifying costs and benefits - a Markov model-based simulation study. BMJ Open 2023; 13:e073254. [PMID: 37993164 PMCID: PMC10668295 DOI: 10.1136/bmjopen-2023-073254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 11/07/2023] [Indexed: 11/24/2023] Open
Abstract
OBJECTIVE Aortic stenosis (AS) is one of the most common acquired cardiac valvular diseases. The success of transcatheter aortic valve implantation (TAVI) for severe AS has led to increasing interest in its use to earlier disease-moderate AS (MAS). DESIGN Model-based study using a Markov microsimulation technique to evaluate the long-term costs and benefits associated with 'early' TAVI. Key data inputs were sourced from the international literature and costs were obtained from Australian sources. SETTING Australian health care system perspective. PARTICIPANTS 10 000 hypothetical MAS patients with or without left ventricular diastolic dysfunction or impaired left ventricular ejection fraction. INTERVENTION Comparing early TAVI to medical management over a life time horizon for MAS patients aged >65 years. We evaluated the cost-effectiveness of offering early TAVI in five scenarios (10%, 25%, 50%, 75% and 90% take-up rates). PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome measure is quality-adjusted life years (QALY) gained and the incremental cost-utility ratio (ICUR). Secondary outcomes are life-years gained and the number of heart failure case avoided. RESULTS Offering early TAVI for MAS patients resulted in both higher healthcare costs and greater benefits (an increase of 3.02 QALYs or 3.99 life-years) per person treated. The ICUR was around $A10 867 and $A11 926 per QALY gained for all five scenarios, with the total cost of early TAVI to the healthcare system being anticipated to be up to $A3.66 billion. Sensitivity analyses indicated a 100% probability of being cost-effective with a willingness to pay threshold of $A50 000/QALY. The benefits remained, even with assumptions of high levels of repeat valve replacement after TAVI. CONCLUSION While ongoing randomised controlled trials will define the benefit of TAVI to MAS patients, these results suggest that this intervention is likely to be cost-effective.
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Affiliation(s)
- Dieu Nguyen
- Deakin Health Economics, Institute for Health Transformation, School of Health and Social Development, Deakin University Faculty of Health, Geelong, Victoria, Australia
| | - Tom Marwick
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Marj Moodie
- Deakin Health Economics, Institute for Health Transformation, School of Health and Social Development, Deakin University Faculty of Health, Geelong, Victoria, Australia
| | - Lan Gao
- Deakin Health Economics, Institute for Health Transformation, School of Health and Social Development, Deakin University Faculty of Health, Geelong, Victoria, Australia
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Abraham B, Farina JM, Fath A, Abdou M, Elbanna M, Suppah M, Sleem M, Eldaly A, Aly M, Megaly M, Agasthi P, Chao CJ, Fortuin D, Alsidawi S, Ayoub C, Alkhouli M, El Sabbagh A, Holmes D, Brilakis ES, Arsanjani R. The impact of moderate aortic stenosis in acute myocardial infarction: A multicenter retrospective study. Catheter Cardiovasc Interv 2023. [PMID: 37146200 DOI: 10.1002/ccd.30676] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/31/2023] [Accepted: 04/22/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Aortic stenosis (AS) is associated with myocardial ischemia through different mechanisms and may impair coronary arterial flow. However, data on the impact of moderate AS in patients with acute myocardial infarction (MI) is limited. AIMS This study aimed to investigate the impact of moderate AS in patients presenting with acute myocardial infarction (MI). METHODS We conducted a retrospective analysis of all patients who presented with acute MI to all Mayo Clinic hospitals, using the Enterprise Mayo PCI Database from 2005 to 2016. Patients were stratified into two groups: moderate AS and mild/no AS. The primary outcome was all cause mortality. RESULTS The moderate AS group included 183 (13.3%) patients, and the mild/no AS group included 1190 (86.7%) patients. During hospitalization, there was no difference between both groups in mortality. Patients with moderate AS had higher in-hospital congestive heart failure (CHF) (8.2% vs. 4.4%, p = 0.025) compared with mild/no AS patients. At 1-year follow-up, patients with moderate AS had higher mortality (23.9% vs. 8.1%, p < 0.001) and higher CHF hospitalization (8.3% vs. 3.7%, p = 0.028). In multivariate analysis, moderate AS was associated with higher mortality at 1-year (odds ratio 2.4, 95% confidence interval [1.4-4.1], p = 0.002). In subgroup analyses, moderate AS increased all-cause mortality in STEMI and NSTEMI patients. CONCLUSION The presence of moderate AS in acute MI patients was associated with worse clinical outcomes during hospitalization and at 1-year follow-up. These unfavorable outcomes highlight the need for a close follow-up of these patients and for timely therapeutic strategies to best manage these coexisting conditions.
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Affiliation(s)
- Bishoy Abraham
- Department of Cardiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Juan M Farina
- Department of Cardiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Ayman Fath
- Department of Cardiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Merna Abdou
- Department of Cardiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Mostafa Elbanna
- Department of Cardiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Mustafa Suppah
- Department of Cardiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Mohamed Sleem
- Department of Cardiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Abdullah Eldaly
- Department of Cardiology, Mayo Clinic Hospital, Jacksonville, Florida, USA
| | - Mohamed Aly
- Department of Cardiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Michael Megaly
- Department of Cardiology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Pradyumna Agasthi
- Department of Cardiology, Mayo Clinic Hospital, Rochester, Minnesota, USA
| | - Chieh-Ju Chao
- Department of Cardiology, Mayo Clinic Hospital, Rochester, Minnesota, USA
| | - David Fortuin
- Department of Cardiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Said Alsidawi
- Department of Cardiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Chadi Ayoub
- Department of Cardiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Mohamad Alkhouli
- Department of Cardiology, Mayo Clinic Hospital, Rochester, Minnesota, USA
| | | | - David Holmes
- Department of Cardiology, Mayo Clinic Hospital, Rochester, Minnesota, USA
| | - Emmanouil S Brilakis
- Department of Cardiology, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Reza Arsanjani
- Department of Cardiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
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Yokoyama Y, Fukuhara S, Takagi H, Kuno T. Natural history of moderate aortic stenosis and predictors for mortality: Systematic review and Meta-analysis. J Cardiol 2023:S0914-5087(23)00056-4. [PMID: 36963660 DOI: 10.1016/j.jjcc.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/18/2023] [Accepted: 03/04/2023] [Indexed: 03/26/2023]
Abstract
Although the current guidelines advocate imaging surveillance for moderate aortic stenosis (AS), recent studies suggest a worse prognosis associated with moderate AS than previously reported. Considering the recent paradigm shift in AS management, the risk/benefit profile of aortic valve replacement (AVR) for moderate AS needs to be re-evaluated. Herein, we conducted meta-analyses of natural history and risk predictors in patients with moderate AS. PubMed and EMBASE were searched through May 2022 to identify studies that investigated the natural history of patients with moderate AS. Meta-analyses with random effects model were conducted. Our analysis included 20 observational studies which enrolled a total of 11,114 patients with moderate AS. The rate of all-cause death was 11.0 [95 % confidence interval (CI), 7.6-14.4] per 100 patients per year. Surgical or transcatheter AVR occurred at a rate of 8.5 (95 % CI, 6.2-10.8; I2, 98.9 %) per 100 patients per year. Occurrence of AVR during follow-up [hazard ratio (HR) (95 % CI) =0.56 (0.42-0.75), p < 0.001] and early AVR for moderate AS [HR (95 % CI) = 0.47 (0.25-0.90), p = 0.02] were associated with significantly lower all-cause mortality, while left ventricular ejection fraction <50 % [HR (95 % CI) =1.84 (1.33-2.57), p = 0.0003] and symptomatic status [HR (95 % CI) = 1.52 (1.32-1.75), p < 0.0001] were associated with increased all-cause mortality. Sex difference was not related to all-cause mortality. Our meta-analysis suggested that moderate AS was associated with high mortality, especially in low left ventricular systolic function or symptomatic patients. In addition, significant portion of the patients underwent AVR during follow-up.
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Affiliation(s)
- Yujiro Yokoyama
- Department of Surgery, St. Luke's University Health Network, PA, USA
| | - Shinichi Fukuhara
- Department of Cardiothoracic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka, Medical Center, Shizuoka, Japan
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, NY, USA.
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7
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Franke KB, Bhatia D, Roberts-Thomson RL, Psaltis PJ. Aortic valve replacement reduces mortality in moderate aortic stenosis: a systematic review and meta-analysis. J Geriatr Cardiol 2023; 20:61-67. [PMID: 36875167 PMCID: PMC9975481 DOI: 10.26599/1671-5411.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND With the introduction of transcatheter aortic valve replacement and an evolving understanding of the natural progression and history of aortic stenosis, the potential for earlier intervention in appropriate patients is promising; however, the benefit of aortic valve replacement in moderate aortic stenosis remains unclear. METHODS Pubmed, Embase, and the Cochrane Library databases were searched up until 30th of December 2021 using keywords including moderate aortic stenosis and aortic valve replacement. Studies reporting all-cause mortality and outcomes in early aortic valve replacement (AVR) compared to conservative management in patients with moderate aortic stenosis were included. Hazard ratios were generated using random-effects meta-analysis to determine effect estimates. RESULTS 3470 publications were screened with title and abstract review, which left 169 articles for full-text review. Of these studies, 7 met inclusion criteria and were included, totalling 4,827 patients. All studies treated AVR as a time-dependent co-variable in cox-regression multivariate analysis of all-cause mortality. Intervention with surgical or transcatheter AVR was associated with a 45% decreased risk of all-cause mortality (HR = 0.55 [0.42-0.68], I 2 = 51.5%, P < 0.001). All studies were representative of the overall cohort with appropriate sample sizes, with no evidence of publication, detection, or information biases in any of the studies. CONCLUSION In this systematic review and meta-analysis, we report a 45% reduction in all-cause mortality in patients with moderate aortic stenosis who were treated with early aortic valve replacement compared to a strategy of conservative management. Randomised control trials are awaited to determine the utility of AVR in moderate aortic stenosis.
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Affiliation(s)
- Kyle B Franke
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia.,Vascular Research Centre, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Dimple Bhatia
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia
| | | | - Peter J Psaltis
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia.,Vascular Research Centre, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, Australia.,Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
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8
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Stassen J, Ewe SH, Pio SM, Pibarot P, Redfors B, Leipsic J, Genereux P, Van Mieghem NM, Kuneman JH, Makkar R, Hahn RT, Playford D, Marsan NA, Delgado V, Ben-Yehuda O, Leon MB, Bax JJ. Managing Patients With Moderate Aortic Stenosis. JACC Cardiovasc Imaging 2023:S1936-878X(22)00741-0. [PMID: 36881428 DOI: 10.1016/j.jcmg.2022.12.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 11/02/2022] [Accepted: 12/02/2022] [Indexed: 02/10/2023]
Abstract
Current guidelines recommend that clinical surveillance for patients with moderate aortic stenosis (AS) and aortic valve replacement (AVR) may be considered if there is an indication for coronary revascularization. Recent observational studies, however, have shown that moderate AS is associated with an increased risk of cardiovascular events and mortality. Whether the increased risk of adverse events is caused by associated comorbidities, or to the underlying moderate AS itself, is incompletely understood. Similarly, which patients with moderate AS need close follow-up or could potentially benefit from early AVR is also unknown. In this review, the authors provide a comprehensive overview of the current literature on moderate AS. They first provide an algorithm that helps to diagnose moderate AS correctly, especially when discordant grading is observed. Although the traditional focus of AS assessment has been on the valve, it is increasingly acknowledged that AS is not only a disease of the aortic valve but also of the ventricle. The authors therefore discuss how multimodality imaging can help to evaluate the left ventricular remodeling response and improve risk stratification in patients with moderate AS. Finally, they summarize current evidence on the management of moderate AS and highlight ongoing trials on AVR in moderate AS.
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Affiliation(s)
- Jan Stassen
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Cardiology, Jessa Hospital, Hasselt, Belgium
| | - See Hooi Ewe
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Stephan M Pio
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Université Laval, Québec City, Québec, Canada
| | - Bjorn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jonathon Leipsic
- Departments of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Philippe Genereux
- Department of Cardiology, Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA
| | - Nicolas M Van Mieghem
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jurrien H Kuneman
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Raj Makkar
- Department of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Rebecca T Hahn
- Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - David Playford
- Department of Cardiology, University of Notre Dame, Fremantle, Western Australia, Australia
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ori Ben-Yehuda
- Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Martin B Leon
- Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands; Turku Heart Center, University of Turku and Turku University Hospital, Turku, Finland.
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9
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Ito S, Oh JK. Aortic Stenosis: New Insights in Diagnosis, Treatment, and Prevention. Korean Circ J 2022; 52:721-736. [PMID: 36217595 PMCID: PMC9551229 DOI: 10.4070/kcj.2022.0234] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 09/07/2022] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Saki Ito
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
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10
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Coisne A, Scotti A, Latib A, Montaigne D, Ho EC, Ludwig S, Modine T, Généreux P, Bax JJ, Leon MB, Bauters C, Granada JF. Impact of Moderate Aortic Stenosis on Long-Term Clinical Outcomes: A Systematic Review and Meta-Analysis. JACC Cardiovasc Interv 2022; 15:1664-1674. [PMID: 35981841 DOI: 10.1016/j.jcin.2022.06.022] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 05/31/2022] [Accepted: 06/14/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND The clinical course of patients with moderate aortic stenosis (AS) remains incompletely defined. OBJECTIVES This study sought to analyze the clinical course of moderate AS and compare it with other stages of the disease. METHODS Multiple electronic databases were searched to identify studies on adult moderate AS. Random-effects models were used to derive pooled estimates. The primary endpoint was all-cause death. The secondary endpoints were cardiac death, heart failure, sudden death, and aortic valve replacement. RESULTS Among a total of 25 studies (12,143 moderate AS patients, 3.7 years of follow-up), pooled rates per 100 person-years were 9.0 (95% CI: 6.9 to 11.7) for all-cause death, 4.9 (95% CI: 3.1 to 7.5) for cardiac death, 3.9 (95% CI: 1.9 to 8.2) for heart failure, 1.1 (95% CI: 0.8 to 1.5) for sudden death, and 7.2 (95% CI: 4.3 to 12.2) for aortic valve replacement. Meta-regression analyses detected that diabetes (P = 0.019), coronary artery disease (P = 0.017), presence of symptoms (P < 0.001), and left ventricle (LV) dysfunction (P = 0.009) were associated with a significant impact on the overall estimate of all-cause death. All-cause mortality was higher in patients with reduced LV ejection fraction (<50%) than with normal LV ejection fraction: 16.5 (95% CI: 5.2 to 52.3) and 4.2 (95% CI: 1.4 to 12.8) per 100 person-years, respectively. Compared with moderate AS, the incidence rate difference of all-cause mortality was -3.9 (95% CI: -6.7 to -1.1) for no or mild AS and +2.2 (95% CI: +0.8 to +3.5) for severe AS patients. CONCLUSIONS Moderate AS appears to be associated with a mortality risk higher than no or mild AS but lower than severe AS, which increases in specific population subsets. The impact of early intervention in moderate AS patients having high-risk features deserves further investigation.
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Affiliation(s)
- Augustin Coisne
- Cardiovascular Research Foundation, New York, New York, USA; Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA; INSERM U1011-EGID, Centre Hospitalier Universitaire de Lille, Institut Pasteur de Lille, Université de Lille, Lille, France.
| | - Andrea Scotti
- Cardiovascular Research Foundation, New York, New York, USA; Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA.
| | - Azeem Latib
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - David Montaigne
- INSERM U1011-EGID, Centre Hospitalier Universitaire de Lille, Institut Pasteur de Lille, Université de Lille, Lille, France
| | - Edwin C Ho
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Sebastian Ludwig
- Cardiovascular Research Foundation, New York, New York, USA; Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Thomas Modine
- Department of Cardiology and Cardio-Vascular Surgery, Hôpital Cardiologique de Haut-Leveque, Bordeaux University Hospital, Bordeaux, France
| | - Philippe Généreux
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA
| | - Jeroen J Bax
- Leiden University Medical Center, Leiden, the Netherlands
| | - Martin B Leon
- Cardiovascular Research Foundation, New York, New York, USA
| | - Christophe Bauters
- INSERM U1167, Centre Hospitalier Universitaire de Lille, Institut Pasteur de Lille, Université de Lille, Université Lille, Lille, France
| | - Juan F Granada
- Cardiovascular Research Foundation, New York, New York, USA
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11
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Gao L, Nguyen D, Moodie M. Economic Burden of Dementia Caused by Cardiovascular Disease in Australia. J Alzheimers Dis 2022; 86:601-612. [DOI: 10.3233/jad-215368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: The established link between cardiovascular disease (CVD) and dementia may provide new insights into dementia prevention. Objective: It aims to quantify the burden of dementia attributable to people with CVD. Methods: A Markov microsimulation model was developed to simulate the lifetime cost and quality-adjusted life-years (QALYs) related to people with and without CVD in Australia. A de-novo systematic review was undertaken to identify all evidence around the association between CVD [i.e., stroke, myocardial infarction (MI), atrial fibrillation (AF), and heart failure (HF)] and the risk of developing dementia. Incremental costs and QALY losses were estimated for people by type of CVD compared to the general Australian population without CVD. Results: Of the comprehensive literature search, 19 observational studies were included in the qualitative synthesis. Patients who had CVD incurred both higher healthcare costs over their lifetime (ranging from $73,131 for patients with AF to $127,396 for patients with HF) and fewer QALYs gains (from –1.099 for patients with MI to –5.163 for patients with stroke), compared to people who did not have CVD. The total incremental economic burden of dementia from patients aged 65 years and over with CVD was $6.45 billion (stroke), $11.89 billion (AF), $17.57 billion (MI), or $7.95 billion (HF) over their remaining life expectancy. Conclusion: The results highlighted the importance of CVD prevention to reduce the CVD burden and decrease the prevalence of dementia. Interventions that target patients with dementia risk factors like CVD may prove to be effective and cost-effective strategies.
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Affiliation(s)
- Lan Gao
- Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Australia
| | - Dieu Nguyen
- Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Australia
| | - Marj Moodie
- Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Australia
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12
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Choi JY. Expanding Role of Left Atrial Strain in Valvular Heart Disease. Korean Circ J 2022; 52:218-219. [PMID: 35257533 PMCID: PMC8907990 DOI: 10.4070/kcj.2022.0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 02/02/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
- Jah Yeon Choi
- Cardiovascular Center, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
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13
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Cho DH. Hemodynamic Challenges With Moderate Aortic Stenosis: Beyond Severe Aortic Stenosis. Korean Circ J 2022; 52:887-889. [DOI: 10.4070/kcj.2022.0286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/02/2022] [Accepted: 11/10/2022] [Indexed: 11/27/2022] Open
Affiliation(s)
- Dong-Hyuk Cho
- Division of Cardiology, Department of Internal Medicine, Korea University Medicine, Seoul, Korea
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14
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Itelman E, Vatury O, Kuperstein R, Ben-Zekry S, Fefer P, Barbash I, Klempfner R, Segev A, Feinberg M, Guetta V, Maor E. The Association of Moderate Aortic Stenosis with Poor Survival is Modified by Age and Left Ventricular Function. J Am Soc Echocardiogr 2021; 35:378-386.e3. [PMID: 34915134 DOI: 10.1016/j.echo.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 12/01/2021] [Accepted: 12/01/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Data on the independent association of moderate aortic stenosis (AS) with excess mortality, even when it does not progress to severe AS, is limited. OBJECTIVE To evaluate the association of moderate AS with poor survival and to identify clinically important modifiers of that association. METHODS Consecutive patients who underwent echocardiographic evaluation between 2007 and 2019. All-cause mortality and cancer data were available for all patients from national registries. Cox regression survival models were applied with censoring of patients who developed metastatic cancer, developed > moderate AS, or underwent aortic valve intervention during follow-up. RESULTS The study population included 92,622 patients. There were 2,202 (2%) patients with moderate AS, with a median age of 79 (IQR 70-85), of whom 1,254(57%) were men. During follow-up of 5 (IQR 3-8) years, 19,712 (21%) patients died. The cumulative probability of death at 5 years was higher for moderate AS patients (46% vs. 18% respectively, p Log-rank < .001). Propensity score matching analysis (N=2,896) that included clinical, laboratory, and echocardiographic predictors of poor survival demonstrated that compared with ≤ mild AS, patients with moderate AS were 17% more likely to die (95% CI 1.04-1.30, p = 0.007). Moreover, the model showed that the moderate AS associated risk was ejection fraction (EF) and age-dependent with a more pronounced association among non-octogenarian patients and patients with reduced EF (p for interaction .001 and .016 respectively). CONCLUSION Moderate AS is independently associated with excess mortality, even when it does not progress to severe AS. The associated risk is more pronounced among patients with reduced EF and patients younger than 80 years.
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Affiliation(s)
- Edward Itelman
- Chaim Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ori Vatury
- Chaim Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Raphael Kuperstein
- Chaim Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sagit Ben-Zekry
- Chaim Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Paul Fefer
- Chaim Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Israel Barbash
- Chaim Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Robert Klempfner
- Chaim Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amit Segev
- Chaim Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Micha Feinberg
- Chaim Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Victor Guetta
- Chaim Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Elad Maor
- Chaim Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
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15
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Badiani S, Bhattacharyya S, Aziminia N, Treibel TA, Lloyd G. Moderate Aortic Stenosis: What is it and When Should We Intervene? ACTA ACUST UNITED AC 2021; 16:e09. [PMID: 34188693 PMCID: PMC8201468 DOI: 10.15420/icr.2021.04] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/29/2021] [Indexed: 12/15/2022]
Abstract
Current guidelines recommend aortic valve replacement in patients with severe aortic stenosis in the presence of symptoms or a left ventricular ejection fraction <50%. However, patients with less than severe aortic stenosis may also experience symptoms and recent literature suggests that the prognosis is not as benign as previously reported. There are no recommendations for patients with moderate aortic stenosis and left ventricular dysfunction, despite the high associated morbidity and mortality. There is also some evidence that these patients may benefit from early aortic valve intervention. It is recognised that aortic stenosis not only affects the valve but also has a complex myocardial response. This review discusses the natural history of moderate aortic stenosis along with the role of multimodality imaging in risk stratification in these patients.
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Affiliation(s)
- Sveeta Badiani
- Heart Valve Clinic and Echocardiography Laboratory, Barts Heart Centre, St Bartholomew's Hospital London, UK.,William Harvey Research Institute, Queen Mary University of London UK
| | - Sanjeev Bhattacharyya
- Heart Valve Clinic and Echocardiography Laboratory, Barts Heart Centre, St Bartholomew's Hospital London, UK.,William Harvey Research Institute, Queen Mary University of London UK.,Institute of Cardiovascular Sciences, University College London London, UK
| | - Nikoo Aziminia
- Heart Valve Clinic and Echocardiography Laboratory, Barts Heart Centre, St Bartholomew's Hospital London, UK
| | - Thomas A Treibel
- Heart Valve Clinic and Echocardiography Laboratory, Barts Heart Centre, St Bartholomew's Hospital London, UK.,Institute of Cardiovascular Sciences, University College London London, UK
| | - Guy Lloyd
- Heart Valve Clinic and Echocardiography Laboratory, Barts Heart Centre, St Bartholomew's Hospital London, UK.,William Harvey Research Institute, Queen Mary University of London UK.,Institute of Cardiovascular Sciences, University College London London, UK
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16
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Lee W, Choi W, Kang SH, Hwang IC, Choi HM, Yoon YE, Cho GY. Long-term Prognosis of Mild to Moderate Aortic Stenosis and Coronary Artery Disease. J Korean Med Sci 2021; 36:e47. [PMID: 33559407 PMCID: PMC7870422 DOI: 10.3346/jkms.2021.36.e47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 12/02/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND There is an incomplete understanding of the natural course of mild to moderate aortic stenosis (AS). We aimed to evaluate the natural course of patients with mild to moderate AS and its association with coronary artery disease (CAD). METHODS We retrospectively analyzed 787 patients diagnosed with mild to moderate AS using echocardiography between 2004 and 2010. Cardiac death and aortic valve replacement (AVR) for AS were assessed. RESULTS A median follow-up period was 92 months. Compared to the general population, patients with mild to moderate AS had a higher risk of cardiac death (hazard ratio [HR], 17.16; 95% confidence interval [CI], 13.65-21.59; P < 0.001). Established CAD was detected in 22.4% and associated with a significantly higher risk of cardiac mortality (adjusted HR, 1.62; 95% CI, 1.04-2.53; P = 0.033). The risk of cardiac death was lower when patients were taking statin (adjusted HR, 0.64; 95% CI, 0.41-0.98; P = 0.041), which was clear only after 7 years. Both patients with CAD and on statin tended to undergo more AVR, but the difference was not statistically significant (the presence of established CAD; adjusted HR, 1.63; 95% CI, 0.51-3.51; P = 0.214 and the use of statin; adjusted HR, 1.86; 95% CI, 0.76-4.58; P = 0.177). CONCLUSION Mild to moderate AS does not have a benign course. The presence of CAD and statin use may affect the long-term prognosis of patients with mild to moderate AS.
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Affiliation(s)
- Wonjae Lee
- Division of Cardiology, Department of Internal Medicine, College of Medicine, Seoul National University and Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Wonsuk Choi
- Division of Cardiology, Department of Internal Medicine, College of Medicine, Seoul National University and Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Si Hyuck Kang
- Division of Cardiology, Department of Internal Medicine, College of Medicine, Seoul National University and Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - In Chang Hwang
- Division of Cardiology, Department of Internal Medicine, College of Medicine, Seoul National University and Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hong Mi Choi
- Division of Cardiology, Hallym Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Yeonyee E Yoon
- Division of Cardiology, Department of Internal Medicine, College of Medicine, Seoul National University and Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Goo Yeong Cho
- Division of Cardiology, Department of Internal Medicine, College of Medicine, Seoul National University and Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea.
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17
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Lee JH. Moderate Aortic Valve Stenosis with Left Ventricular Systolic Dysfunction: Potential Role of Early Aortic Valve Replacement. Korean Circ J 2020; 50:801-803. [PMID: 32812409 PMCID: PMC7440998 DOI: 10.4070/kcj.2020.0301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 07/22/2020] [Indexed: 11/11/2022] Open
Affiliation(s)
- Ju Hee Lee
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea.
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