Abstract
Abstract Aims Degenerative aortic stenosis (AS) is the most common heart valve disease among people ≥65 years in developed countries, with an increasing prevalence due to population ageing. A recently proposed staging classification of AS is based on the assumption that there is a continuum in the pathophysiology of LV structural and functional changes induced by AS. Such system showed prognostic ability among patients from the PARTNER 2 trial as well as in asymptomatic subjects with moderate to severe AS, thus challenging the current management of the disease. The aim of our study was to assess the prognostic performance of this staging classification in a real-world cohort of patients undergoing transcatheter aortic valve implantation (TAVI) and to investigate the eventual impact of the procedure on the extent of extra-aortic valve cardiac damage. Methods and results A staging classification was applied to 262 patients from the EffecTAVI Registry. The following criteria for staging classification of cardiac damage were applied at baseline (within 1 month before TAVI) and after the procedure (within 30-day): Stage 0, no extra-aortic valve cardiac damage; Stage 1, LV damage as defined by the presence of LV hypertrophy (LV mass index >95 g/m2 for women, >115 g/m2 for men), severe LV diastolic dysfunction (E/e’ >14) or LV systolic dysfunction (LV ejection fraction, LVEF <50%); Stage 2, left atrial (LA) and/or mitral valve damage as defined by the presence of LA enlargement (LA volume > 34 ml/m2) and/or moderate-severe mitral regurgitation and/or atrial fibrillation; Stage 3, pulmonary vasculature and/or tricuspid valve damage as defined by the presence of systolic pulmonary hypertension (systolic pulmonary arterial pressure, PAPS > 60 mmHg) and/or moderate/severe tricuspid valve regurgitation; Stage 4, right ventricular (RV) damage as defined by the presence of moderate-severe RV systolic dysfunction (tricuspid annular systolic excursion, TAPSE < 17 mm). The primary endpoint of the study was all-cause mortality at 1-year. Secondary endpoints included cerebrovascular accident, myocardial infarction, permanent pacemaker implantation, endocarditis and re-hospitalization for all causes. At baseline, 23 (8.7%) patients were in Stage 0/1 (no cardiac damage/left ventricular damage), 106 (40.4%) in Stage 2 (left atrial or mitral valve damage), 59 (22.5%) in Stage 3 (pulmonary vasculature or tricuspid valve damage) and 74 (28.3%) in Stage 4 (right ventricular damage). At 30-day after TAVI, a lower prevalence of advanced stages of cardiac damage than baseline, mainly driven by a significant improvement in left ventricular diastolic parameters and right ventricular function, was reported. At 1-year, a stepwise increase in mortality rates was observed according to staging at baseline: 4.3% in Stage 0/1, 6.6% in Stage 2, 18.6% in Stage 3 and 21.6% in Stage 4 (p = 0.08). No differences were found in secondary endpoints. Conclusion TAVI has an early beneficial impact on the left ventricular diastolic and right ventricular function. However, the extent of cardiac damage at baseline significantly affects the risk of mortality at 1-year after the procedure.
Highlights
23 (8.7%) patients were in Stage 0/1, 106 (40.4%) in Stage 2, 59 (22.5%) in Stage 3 and 74 (28.3%) in Stage 4
transcatheter aortic valve implantation (TAVI) might be associated with an amelioration of the left ventricular diastolic and right ventricular function, patients with a greater extent of cardiac damage at baseline are at higher risk of mortality at 1-year after the procedure
This system was formulated by leveraging on data of 1,661 patients from the PARTNER 2 trial and proved a powerful predictor of mortality at 1-year after aortic valve intervention.[7]. In our study, including real-world patients, the system retains its prognostic ability as a greater extent of cardiac damage was associated with increased risk of all-cause mortality after TAVI
Summary
Degenerative aortic stenosis (AS) is the most common heart valve disease among people ≥ 65 years in developed countries, with an increasing prevalence due to population ageing.[1, 2] AS commonly leads to left ventricular (LV) pressure overload resulting in concentric hypertrophy that prevents symptoms onset for a long time while yielding progressive left and right ventricular dysfunction and impaired survival. [3, 4]Current guidelines recommend intervention in patients with AS according to the severity of the disease and the presence of the symptoms.[5, 6] benefits of valve replacement may be limited in patients with advanced functional and structural myocardial changes.AS induces structural and functional cardiac changes, recently classified by Genereux et al in a staging model that showed prognostic ability either among patients from the PARTNER 2 trial or in asymptomatic subjects with moderate to severe AS, challenging the current management of the disease.[7, 8]The aim of our study was to assess the prognostic performance of this staging classification in a realworld cohort of patients undergoing transcatheter aortic valve implantation (TAVI) and to investigate the eventual impact of the procedure on the extent of extra-aortic valve cardiac damage.Patient population and data collectionAll consecutive patients with severe symptomatic AS undergoing TAVI between 2014 and 2019 at our institution were enrolled in the EffecTAVI registry. Current guidelines recommend intervention in patients with AS according to the severity of the disease and the presence of the symptoms.[5, 6] benefits of valve replacement may be limited in patients with advanced functional and structural myocardial changes. AS induces structural and functional cardiac changes, recently classified by Genereux et al in a staging model that showed prognostic ability either among patients from the PARTNER 2 trial or in asymptomatic subjects with moderate to severe AS, challenging the current management of the disease.[7, 8]. The EffecTAVI registry has been approved by the local ethic committee and all study-related procedures were carried out in accordance with the Declaration of Helsinki. Written informed consent was obtained for all patients for participation in this registry
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