Evaluation Of Aortic Stenosis Research Articles

Validation of a hand-held ultrasound device in the evaluation of aortic stenosis

Abstract Introduction Hand-held Ultrasound devices (HHUD) are increasingly used in routine clinical practice, although until recently they did not have continuous Doppler. There is no evidence on the usefulness of an HHUD for the assessment of aortic stenosis (AS) in real life. Objective To validate the use of a new HHUD device in a real-life scenario. Material and methods Observational, single-center and prospective study, including patients diagnosed with AS with a previous standard echocardiography. Patients were randomly recruited from a tertiary cardiac imaging laboratory. Immediately after the reference echocardiography performed by an imaging expert, a Cardiology trainee with ASE level II repeated the study blindly with an HHUD. Agreement between the two tests was evaluated by measuring the mean aortic valve gradient (mAG). An intraclass correlation coefficient (ICC) test, linear regression, and Bland-Altman test were performed to compare the two methods. Results 101 patients were recruited. The reference test calculated a mAG of 29 mmHg (19.8 - 42.2) versus a mAG of 27.2 mmHg (16.2 - 43.9) in HHUD. The statistical analysis showed a good correlation between both tests (ICC: 0.87 (95% CI: 0.79 -0.94) and r=0.89 (95% CI: 0.85-0.94) (Figure). The Bland-Altman test showed a non-significant underestimation (1.61 ± 0.9 mmHg; p= 0.09). The HHUD classified 29 cases as severe or major AS compared to 31 in the reference test (kappa= 0.81; 95% CI: 0.68 - 0.94). The HHUD showed an excellent agreement for classification of AS in at least severe AS grade. The kappa analysis had a value of 0.81 (95% CI 0.68 – 0.94) with a global agreement of 92.1%. The positive predictive value was 89.6%. The negative predictive value was 93.1%. Sensitivity and specificity were 83.8% and 95.7%. The rest of the variables evaluated showed poorer agreement. In those patients with obesity, worse acoustic window, atrial fibrillation and critical AS, the agreement was worse. Conclusions The new HHUD evaluated by an operator with limited experience showed good agreement with the reference echocardiographic device in determining the mean aortic gradient.Central picture

An artificial intelligence-based landmark model for early detection of aortic stenosis in Cardiac MRI

Abstract Background The utilisation of ratiometric intensity measures from cardiac magnetic resonance imaging (CMR) offers a promising biomarker for the diagnosis of aortic stenosis (AS)[1]. The Ao:LV ratio, an approximation of AS severity, is determined by comparing the relative blood signal intensity in the aorta and left ventricle (LV) within three-chamber (3Ch) cine sequences[1]. In patients with AS, the blood signal intensity of aortic blood above the valve is diminished compared to that within the LV in steady-state free precession (SSFP) 3Ch CMR cine. Although the Ao:LV ratio serves as a reliable indicator of AS severity, manual computation of this ratio may encounter difficulties due to visual obstructions caused by small LV cavities or prominent papillary muscles. Purpose This study aims to leverage artificial intelligence (AI) to automate the Ao:LV ratio analysis from 3Ch SSFP cine images and introduce the Ao:LA (aorta to left atrium) ratio, thus enhancing the diagnostic accuracy for AS severity. Methods Our methodology extends the ratiometric analysis to include both Ao:LV and Ao:LA ratios in three main steps: first, developing an AI-based algorithm for automated detection and tracking of cardiac landmarks; second, using these landmarks to automatically compute regions of interest (ROIs) in the cardiac chambers; and third, training and validating classification models with 5-fold cross-validation to select the most effective for AS severity classification. The final model's performance is assessed on a holdout test set. Data for model training and evaluation were sourced from CMR scans across three hospitals and two scanner types. Results We analysed 220 patients of which 78 patients had no AS and 122 had AS (mild AS, n = 29; moderate AS; n = 35, severe AS; n = 78). Our model yielded high efficacy in classifying AS, particularly in differentiating any grade of AS from a normal classification, which is clinically relevant. The Ao:LA ratio demonstrated a stronger correlation with AS severity class than Ao:LV, suggesting a more reliable biomarker. The proposed model demonstrated robust performance in AS classification, achieving an Area Under the Curve (AUC) of 0.845 in the automated binary classification of AS at any grade. The model exhibited a precision of 0.889, recall of 0.865, and an F1 score of 0.877 on a holdout set. Conclusion By the integration of AI in automating the analysis of CMR images through a novel ratiometric approach that includes Ao:LV and Ao:LA ratios, our model significantly improves the accuracy of early AS detection. This advancement enhances imaging strategies for AS evaluation, promoting more efficient and effective use of cardiac MRI sequences as a diagnostic tool for aortic stenosis. It has the potential to be implemented in real-time scanning protocols as a clinical decision support system.AI-inferred cardiac landmarks.ROC curve delineating AS prediction.

Aortic valve tissue quantification in bicuspid aortic valve stenosis

Abstract Background The relative contribution of calcific versus noncalcific aortic valve tissue volume to aortic stenosis (AS) in bicuspid aortic valve (BAV) is unclear. Purpose We aimed to assess the association of aortic valve tissue volume quantified by contrast-enhanced CT with echocardiographic AS severity, and diagnostic implication of noncalcific tissue volume for severe AS. Methods We retrospectively identified 234 patients with BAV who had echocardiographic AS severity and contrast-enhanced CT evaluation within six months and left ventricular ejection ≥50%, including 150 severe AS (aortic valve area≤1 cm2 or indexed valve area≤0.6cm2/m2 plus mean grdient≥40mmHg or peak velocity≥4 m/s), 84 nonsevere AS (61 with at least mild AS: peak veloicty≥2.0 m/s plus mean gradient ≥10mmHg, and 23 with normal aortic valve function). Contrast-enhanced CT aortic valve calcific volume and noncalcific (fibrosis) volume were quantified using patient-specific Hounsfield unit thresholds (Figure). Noncontrast CT aortic valve calcium score (AVCscore) was quantified by the Agaston method. CT measurements were indexed to echocardiographic aortic valve annulus area and square-root transformed for the analysis. Results Of 234 patients, the mean age was 64±11 years, and 64% were men. There were positive correlations of indexed calcific volume, noncalcific volume, and inverse correlations of percentages of noncalcific volume (noncalcific volume divided by the sum of calcific and noncalcific volume) with peak velocity and mean gradient (|r|=0.30 to 0.68). Among 150 patients with severe AS, 28 had an AVCscore below the severe AVC threshold (1200 AU in women and 2000 AU in men) while exhibited a higher percentage of noncalcific volume compared to 122 patients with severe AVCscore (67±15% vs. 39±15%, p<0.001). After excluding 122 patients with severe AS and severe AVCscore, the indexed noncalcific volume was associated with severe AS (β±S.E: 0.18±0.07, p=0.005) with an area under the curve of 0.71; in contrast, AVCscore was not (p=0.55). Conclusion Both calcific and noncalcific aortic valve tissue volume contribute to AS severity in patients with BAV. Notably, noncalcific tissue volume is a key factor in determining severe AS in patients without severe AVCscore, suggesting its potential diagnostic value.Figure

Challenges in the Evaluation of Aortic Stenosis: A Guide to Multimodal Imaging

Severe Aortic stenosis (AS) is characterised by a late peaking crescendo-decrescendo systolic murmur and a diminished/absent second heart sound. Echocardiographic assessment of AS severity, based on transvalvular velocities / pressure gradients and calculated aortic valve area (AVA), confirms the diagnosis and allows timely intervention. Nevertheless, diagnostic uncertainty exists in cases of discordant measurements, confounders, and symptoms-measurement discrepancies. This guide outlines an approach to the use of multimodal imaging in the diagnosis and staging of AS.

Moderate aortic stenosis: Navigating the uncharted.

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.

Impact of arteriovenous fistula on flow states in the evaluation of aortic stenosis among ESKD patients on dialysis.

An arteriovenous fistula (AVF) in patients with end-stage kidney disease (ESKD) can influence flow states. We sought to evaluate if assessment of aortic stenosis (AS) by transthoracic echocardiographic (TTE) differs in the presence of AVF compared to other dialysis accesses in patients on dialysis. We identified consecutive ESKD patients on dialysis and concomitant AS from a single center between January 2000 and March 2021. We analyzed TTE parameters of AS severity (velocities, gradients, aortic valve area [AVA]) and hemodynamics (cardiac output [CO], valvuloarterial impedance [Zva]) and compared AS parameters in patients with AVF versus other dialysis access. The cohort included 94 patients with co-prevalent ESKD and AS; mean age 66years, 71% male; 43% Black, 24% severe AS. Dialysis access: 53% AVF, 47% others. In the overall cohort, no significant differences were noted between AVF versus non-AVF in AVA/CO/Zva, but with notable subgroup differences. In mild AS, CO was significantly higher in AVF versus non-AVF (6.3 vs. 5.2L/min; p=.04). In severe AS, Zva was higher in the AVF versus non-AVF (4.6 vs. 3.6mm Hg/mL/m2 ). With increasing AS severity in the AVF group, CO decreased, coupled with increase in Zva, likely counterbalancing the net hemodynamic impact of the AVF. Among ESKD patients with AS, TTE parameters of flow states and AS severity differed in those with AVF versus other dialysis accesses and varied with progression in severity of AS. Future longitudinal assessment of hemodynamic parameters in a larger cohort of co-prevalent ESRD and AS would be valuable.

Aortic Valve Stenosis and Cancer: Problems of Management.

Aortic valve stenosis and malignancy frequently coexist and share the same risk factors as atherosclerotic disease. Data reporting the prognosis of patients with severe aortic stenosis and cancer are limited. Tailoring the correct and optimal care for cancer patients with severe aortic stenosis is complex. Cancer patients may be further disadvantaged by aortic stenosis if it interferes with their treatment by increasing the risk associated with oncologic surgery and compounding the risks associated with cardiotoxicity and heart failure (HF). Surgical valve replacement, transcatheter valve implantation, balloon valvuloplasty, and medical therapy are possible treatments for aortic valve stenosis, but when malignancy is present, the choice between these options must take into account the stage of cancer and associated treatment, expected outcome, and comorbidities. Physical examination and Doppler echocardiography are critical in the diagnosis and evaluation of aortic stenosis. The current review considers the available data on the association between aortic stenosis and cancer and the therapeutic options.

Pitfalls and Tips in the Assessment of Aortic Stenosis by Transthoracic Echocardiography.

Aortic stenosis (AS) is a valvular heart disease that significantly contributes to cardiovascular morbidity and mortality worldwide. The condition is characterized by calcification and thickening of the aortic valve leaflets, resulting in a narrowed orifice and increased pressure gradient across the valve. AS typically progresses from a subclinical phase known as aortic sclerosis, where valve calcification occurs without a transvalvular gradient, to a more advanced stage marked by a triad of symptoms: heart failure, syncope, and angina. Echocardiography plays a crucial role in the diagnosis and evaluation of AS, serving as the primary non-invasive imaging modality. However, to minimize misdiagnoses, it is crucial to adhere to a standardized protocol for acquiring echocardiographic images. This is because, despite continuous advances in echocardiographic technology, diagnostic errors still occur during the evaluation of AS, particularly in classifying its severity and hemodynamic characteristics. This review focuses on providing guidance for the imager during the echocardiographic assessment of AS. Firstly, the review will report on how the echo machine should be set to improve image quality and reduce noise and artifacts. Thereafter, the review will report specific emphasis on accurate measurements of left ventricular outflow tract diameter, aortic valve morphology and movement, as well as aortic and left ventricular outflow tract velocities. By considering these key factors, clinicians can ensure consistency and accuracy in the evaluation of AS using echocardiography.

Abstract 11290: Sex Differences in the Progression and Long-Term Outcomes of Native Mild to Moderate Aortic Stenosis

Background: Despite evidence of sex-based divergences in the natural history of aortic stenosis (AS), there is limited data on the sex differences in the hemodynamic progression and long-term outcomes of early-stage AS. Methods: This is a retrospective longitudinal study of patients aged ≥ 60 years with mild to moderate native AS who were identified from a tertiary care referral center between 2008-2016 and followed until 2018. All patients had at minimum 2 echocardiograms. The primary outcomes of all-cause mortality and aortic valve replacement (AVR) were both assessed by time-to-event analyses with multivariable-adjusted Cox regression. The secondary outcome of AS progression was assessed by annualized changes in echocardiographic parameters in a 1:1 propensity-matched group of males and females. Results: Of 2,660 included patients followed over a median duration of 5.6 years, the mean age was 74 years and 1,128 (42%) were female. There was no difference in all-cause mortality between sexes, irrespective of age, baseline AS severity, and receipt of AVR. Relative to males, females had a lower risk of AVR (aHR=0.77, 95% CI [0.65-0.92]; p=0.004) irrespective of age, type of aortic valve and baseline severity of AS (Figure). This finding persisted on sensitivity analyses excluding patients with a history of coronary artery disease, prior coronary bypass surgery (CABG), and who underwent concomitant CABG and AVR. On 1:1 propensity-matched analysis, females had significantly slower annualized decrease in indexed aortic valve area (-0.039 vs. -0.021 cm 2 /m 2 /year, p=0.04) and slower increase in mean gradient (1.60 vs. 1.01 mmHg/year, p<0.001),and maximum transvalvular velocity (0.08 vs. 0.11 m/s/year; p=0.04). Conclusion: In patients with mild to moderate AS, females had slower hemodynamic progression of AS and lower incidence of AVR despite similar mortality between sexes. Our findings suggest the need for sex-specific evaluation and management of native AS.

Imaging Challenges in Patients with Severe Aortic Stenosis and Heart Failure: Did We Find a Way Out of the Labyrinth?

Aortic stenosis (AS) is the most frequent degenerative valvular disease in developed countries. Its incidence has been constantly rising due to population aging. The diagnosis of AS was considered straightforward for a very long time. High gradients and reduced aortic valve area were considered as “sine qua non” in diagnosis of AS until a growing body of evidence showed that patients with low gradients could also have severe AS with the same or even worse outcome. This completely changed the paradigm of AS diagnosis and involved large numbers of parameters that had never been used in the evaluation of AS severity. Low gradient AS patients may present with heart failure (HF) with preserved or reduced left ventricular ejection fraction (LVEF), associated with changes in cardiac output and flow across the aortic valve. These patients with low-flow low-gradient or paradoxical low-flow low-gradient AS are particularly challenging to diagnose, and cardiac output and flow across the aortic valve have become the most relevant parameters in evaluation of AS, besides gradients and aortic valve area. The introduction of other imaging modalities in the diagnosis of AS significantly improved our knowledge about cardiac mechanics, tissue characterization of myocardium, calcium and inflammation burden of the aortic valve, and their impact on severity, progression and prognosis of AS, not only in symptomatic but also in asymptomatic patients. However, a variety of novel parameters also brought uncertainty regarding the clinical relevance of these indices, as well as the necessity for their validation in everyday practice. The aim of this review is to summarize the prevalence of HF in patients with severe AS and elaborate on the diagnostic challenges and advantages of comprehensive multimodality cardiac imaging to identify the patients that may benefit from surgical or transcatheter aortic valve replacement, as well as parameters that may help during follow-up.

Abstract 9915: Impact of Arteriovenous Fistula and Non-Physiological Flow States in the Evaluation of Aortic Stenosis Among End-Stage Kidney Disease Patients on Dialysis

Introduction: Aortic stenosis (AS) progresses rapidly and unpredictably in ESKD and is an independent risk factor for mortality. Making an accurate diagnosis and assessing severity of AS on TTE is critical to inform management decisions. TTE parameters of AS severity could be adversely impacted by presence of an arteriovenous fistula (AVF) and resultant non-physiological flow states in ESKD. We aim to evaluate prevalence of non-physiological flow states in patients with ESKD and AS with AVF vs. other dialysis access types. We hypothesized that TTE parameters vital to accurate determination of severity of AS will defer in ESKD patients with AVF compared to other types of dialysis access. Methods: In this retrospective observational study, we identified unique ESKD patients on dialysis and concomitant AS from a single center between 1/1/2000 to 1/1/2021. Severity of AS was defined per 2014 AHA/ACC guidelines. We analyzed the TTE parameters of AS severity according to dialysis access modality. Aortic valve area (AVA) was determined by the continuity equation. Results: We included 94 patients; mean age 66 yrs, 71% male; 43% black, 40% white. Severe AS was present in 18%, moderate in 41% and mild in 41%. Fifty-three percent of patients had AVF, 17% arteriovenous graft, 15% peritoneal dialysis catheter, and 15% central venous access catheter. TTE parameters of flow state and AS severity did not demonstrate any significant differences across different dialysis access modalities. (Table 1) The results were similar after adjusting for AS severity grades. Conclusions: Among ESKD patients with AS, flow states and TTE parameters of AS severity were not different in the presence of an AVF compared to other dialysis access modalities. This study provides reassurance that conventional TTE parameters, including peak velocity, mean gradient, and AVA used to estimate AS severity can be utilized reliably in dialysis patients with AVF since non-physiological flow states were not prevalent.

Deep learning for automated left ventricular outflow tract diameter measurements in 2D echocardiography

Abstract Background Left ventricular outflow tract diameter (LVOTd) is routinely measured to calculate stroke volume and estimate aortic valve area by the continuity equation. Despite LVOTd being regularly measured clinically, significant inter- and intraobserver variability is evident. This variability is highly impactful on both aortic stenosis evaluation and cardiac output calculation due to the squaring of the LVOT radius. Purpose We aimed to investigate if LVOTd measurements from clinical echocardiographic examinations could be used in a deep learning (DL) model to automatically perform LVOTd measurements with equivalent accuracy and improved consistency compared to current practice. Methods Data was collected from clinical echocardiographic examinations performed on 656 consecutive patients admitted to the cardiac catheterization laboratory at a university hospital in January – December 2018. Parasternal views with cardiologist annotated LVOTd coordinates were assessed for 1314 echocardiographic still images. The quality of the still image and annotated LVOT ground truth were individually graded as high, medium and low by experienced cardiologists to establish a rigorous training basis. Spatial geometry data was preserved for each still image in order to distinguish between different degrees of image zoom. Data was randomly split into training, validation and testing sets (68%, 17%, 15%). A fully convolutional network based on the Resnet50 architecture was used with a custom loss function with heatmap regression. Image augmentations were added to extend the dataset. Results When including echocardiographic images of any quality (n=1314) in the model training and inference, the median absolute difference between cardiologist LVOTd and DL LVOTd was 0.97 mm (95% Confidence interval (CI) 0.79–1.14). Using only high and medium quality still images and ground truth (n=869) in the training and inference, median absolute difference decreased to 0.81 mm (95% CI 0.60–0.96). Adding image augmentations to this dataset further improved the model, resulting in a median LVOTd absolute difference of 0.66 mm (95% CI 0.51–0.78). The LVOTd error in inference increased with decreasing image quality, as shown in Figure 1, with two predictions (0.9%) failing completely. Conclusion Deep learning models are capable of measuring LVOTd with comparable accuracy to cardiologists when trained on clinical data. Data quality affects both training and inference. Even with a slightly lower accuracy when used on lower quality echocardiographic images, DL-assisted LVOT measurement has a clear potential to increase repeatability and consistency of LVOTd measurements. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Research Council of Norway (Norges forskningsråd) Figure 1

SEX DIFFERENCES IN AORTIC STENOSIS PROGRESSION IN A MURINE MODEL

<h3>BACKGROUND</h3> Sex differences in stenosed aortic valve have been recently demonstrated, however sex-specific progression of aortic stenosis (AS) remains unstudied. This study aims to examine the impact of sex and sex hormones on the progression of AS in a murine model of AS. <h3>METHODS AND RESULTS</h3> LDL-/- ApoB100/100 IGF-II+/- mice fed with high fat/sucrose/cholesterol diet were divided in 6 groups: intact males (IM), intact females (IF), castrated males (CM), ovariectomized females (OF), CM with testosterone supplementation (CMT) and OF with estrogen supplementation (OFE). Echocardiographic evaluation of AS and valve tissue histological analysis were performed at 12 and 36 weeks. Among male mice, IM had the fastest progression of peak aortic jet velocity (Vpeak) (24.2±5.7 cm/s; p < 0.001) compared to CM (6.2±1.4; p=0.42) who did not progress significantly, and CMT had a significant intermediate progression of Vpeak (15.1±3.5; p=0.002; p for interaction=0.02 - Figure). Accordingly, indexed aortic valve area (AVAi) decreased significantly in the IM and CMT groups, while the decrease in AVAi was smaller and did not reach statistical significance in the CM group (IM: -0.68±0.21cm2/m2; p < 0.001 vs. CMT: -0.40±0.20 cm2/m2; p < 0.001 vs. CM: -0.15±0.28 cm2/m2; p=0.07; p for interaction < 0.001). Among female mice, Vpeak progression was significant and similar in all groups (IF: 25.8±5.3; p < 0.001; OF: 12.8±2.6; p=0.03; OFE: 18.5±3.4; p=0.003; p=0.29 - Figure). Accordingly, AVAi decreased in the three female groups (IF: -0.60±0.22cm2/m2; p < 0.001, OFE: -0.66±0.19 cm2/m2; p < 0.001, OF: -0.43±0.22 cm2/m2; p < 0.001; p for interaction < 0.001). Aortic valve leaflets were thicker at 36 weeks compared to 12 weeks (median [IQR]: 0.143[0.120-0.188] vs.0.103[0.056-0.120] mm; p < 0.001). The largest decrease of leaflet fibrosis was seen in CMT (-13.76±4.53%), compared to CM (-8.67±4.53%) and IM (-5.18±7.22%) (p=0.02). Leaflet fibrosis increased among female groups (OF: 14.43±7.04; IF: 5.31±14.41; OFE: 9.21±17.04%; p=0.46). At 12 weeks, we found no evidence of leaflet calcification. At 36weeks, female mice had lower amounts of calcification than male mice (IF: 0.00[0.00-0.43], OF: 0.40[0.17-1.38], OFE: 0.45[0.07-1.85], IM: 6.01[1.87-40.7], CMT: 4.00[0.00-7.05], CM: 1.66[0.06-21.80] %; p=0.02). <h3>CONCLUSION</h3> In this murine model of AS, testosterone played an important role in hemodynamic AS progression in male mice unlike estrogen on hemodynamic AS progression in female mice. Despite valve thickness increasing in all groups, the composition of the valve leaflet was different between male and female mice, and testosterone presence was associated with higher calcification of the valve.

Value of non-apical echocardiographic views in the up-grading of patients with aortic stenosis

Purpose. Echocardiography assessment from apical five-chamber view (A5CV) is the standard technique for aortic stenosis (AS) grading. Data on non-apical views, such as right parasternal (RPV), subcostal (SCV) and suprasternal notch (SSNV), is scarce and constitutes the aim of our study. Methods. We designed an observational study that included patients with AS recruited prospectively in whom the stenosis was graded by echocardiography from A5CV and non-apical view. The value of non-apical views in up-grading the stenosis severity (primary objective), the prognostic relevance of such reclassification and the feasibility and reproducibility of non-apical views assessment (secondary objectives) was evaluated. Results. Feasibility of AS appraisal from RPV, SCV and SSNV was 78%, 81% and 56%, respectively (SCV vs SSNV, p = .009). AS were up-graded from non-apical views according to peak gradient, mean gradient, area and indexed area by 24%, 17%, 24% and 22%, respectively (p < .0001). Non-apical views reclassified from non-severe to severe AS, from low gradient severe to high gradient severe AS and from non-critical to critical AS 19%, 23% and 3% of cases (p < .0001). The 4-years hard cardiac events rate was 41% in patients with non-severe AS, 67% in patients with severe AS from non-apical views, 68% in patients with severe AS from A5CV and 80% in patients with severe AS from A5CV and non-apical views (p < .001). Reproducibility of AS evaluation from non-apical views was fair to excellent (intraclass correlation coefficients: SSNV = 0.44, RPV = 0.61, SCV = 0.92). Conclusion. Assessment of AS from non-apical views is feasible, reproducible and valuable over A5CV; its use is encouraged.

Low-gradient aortic stenosis in patients with concomitant mitral regurgitation - a subgroup analysis from the German aortic valve registry (GARY)

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by German Cardiac Society, German Society for Thoracic and Cardiovascular Surgery, and German Heart Foundation. Statistical funding support by the German Center for Cardiovascular Research/Deutsches Zentrum für Herz-Kreislauf Forschung (DZHK). Background Patients with severe aortic stenosis (AS) frequently present concomitant mitral regurgitation (MR), which may interfere with echocardiographic measurement of mean pressure gradient (MPG), maximal flow velocity and aortic valve area (AVA). Purpose We therefore, aimed to investigate the impact of different grades of MR on parameters of AS severity in a large cohort of all-comer patients with severe AS, prospectively included in the national German Aortic Registry (GARY). Methods All patients undergoing transcatheter or surgical aortic valve replacement for severe AS enrolled in GARY between 2011 and 2017 were considered for this analysis. After excluding cases with mitral stenosis and unknown causes of MR, 119,641 patients were considered for the present study. Based on LVEF, the study population was divided into the following subgroups: group 1 (LVEF &amp;lt; 30%, n = 7545), group 2 (LVEF 30-50%, n = 30,116), and group 3 (LVEF &amp;gt; 50%, n = 81,980). Differences in the values of the mPG were explored in each group and in relation to the decremental values of aortic valve area (AVA). Results Overall, 37,489 (31.3%) patients had no MR, 77,890 (65.1%) had MR grade I-II, and 4262 (3.6%) had MR grade III-IV. In group 1, 2 and 3, no MR was reported in 1339 (17.7%), 7612 (25.3%) and 28,538 (34.8%) patients respectively. MR grade I-II was more frequently observed (group 1 5621 [74.5%] vs. group 2 20,972 [69.6%] vs. group 3 51,297 [62.6%]), whereas MR grade III-IV was observed less frequently and present only in 585 (7.7%), 1532 (5.1%) and 2145 (2.6%) patients in subgroups 1, 2 and 3, respectively. The aortic mPG was significantly lower in subgroup 1 compared to 2 and 3 (33.74 ± 14.93 versus 41.4 ± 16.47 and 46 ± 16.19mmHg respectively, p &amp;lt; 0.001). With increasing severity of MR, there was a significant reduction of the aortic mPG in each LVEF subgroup (Figure 1). This pattern was maintained irrespective of the AVA value. Conclusions In patients with severe AS, concomitant MR may potentially affect diagnostic accuracy of echocardiographic AS evaluation. In this first GARY analysis of patients with severe AS and concomitant MR, we observed that increasing MR severity affects transvalvular aortic mPG and results in a low-gradient AS pattern. In contrast, AVA is a robust diagnostic parameter for the diagnosis of true severe AS that maintains its validity independently of LVEF and severity of concomitant MR. Abstract Figure 1

Correlation between ejection dynamic parameters and usual echocardiographic methods for assessing aortic stenosis: A prospective study

Aortic stenosis (AS) was the most frequent valve disease referred for surgical treatment in developed countries. The management of the disease depends of AS severity. Echocardiography is the mainstay of assessment, and three parameters are recommended for AS severity evaluation: effective orifice area, mean aortic gradient, and peak jet velocity. Our study was to evaluate acceleration time (AT) and the ratio the AT/ET (ejection time) ratio as diagnostic parameters in AS and to analyse the defining characteristics of the aortic waveform. Patients with AS were prospectively enrolled. Quantitative echocardiographic Doppler parameters including ejection dynamics (AT, ET, and AT/ET ratio) as well as conventional and clinical parameters were analysed. AT, ET, and AT/ET ratio were calculated in different stages of AS. Fifty-one patients were included (mean age, 56 years; 54% women), of whom 37 (74%) had severe AS and 14 (26%) patients had moderate AS; AT was higher in patients with higher levels of severity (121 vs. 85 msec, P < 0.001), as well as AT/ET ratios (28% vs. 37%, P < 0.001) ( Table 1 ). Using a cut-off of 80 msec for AT and 32% for AT/TE, while there were no differences in ET (297 vs. 300 ms, P = 0.66). Receiver operating characteristic analysis showed that AT and AT/ET ratio could discriminate severe AS, whereas ET could not. We found good correlations between both ejection parameters (AT and AT/ET ratio) and all the usual echocardiographic methods for assessing AS ( Fig. 1 ). The present study shows that systolic time intervals, particularly AT and AT/ET ratio, are easy and accurate methods that are related to AS severity and could be used as alternatives in the echocardiographic assessment of this disease.

Direct Planimetry of Left Ventricular Outflow Tract Area by Simultaneous Biplane Imaging: Challenging the Need for a Circular Assumption of the Left Ventricular Outflow Tract in the Assessment of Aortic Stenosis

Evaluation of aortic stenosis (AS) requires calculation of aortic valve area (AVA), which relies on the assumption of a circular-shaped left ventricular outflow tract (LVOT). However, the LVOT is often elliptical, and the circular assumption underestimates the true LVOT area (LVOTA). Biplane imaging using transthoracic echocardiography allows direct planimetry of LVOTA. The aim of this study was to assess the feasibility of obtaining LVOTA using this technique and its impact on the discordance between AVA and gradient criteria in AS grading. We prospectively studied 134 patients (median age, 80years; interquartile range, 73-87years; 39% women) with AS, including 82 (61%) with severe AS and 52 (39%) with mild or moderate AS. LVOTA was traced using direct planimetry (LVOTAbiplane) and compared with LVOTA calculated using the circular assumption (LVOTAcirc). In a subset of patients who underwent cardiac computed tomography, direct planimetry of LVOTA was used as a reference standard. LVOTAbiplane was significantly larger than LVOTAcirc (4.20cm2 [interquartile range, 3.66-4.90cm2] vs 3.73cm2 [interquartile range, 3.14-4.15cm2], P<.001). Among 30 patients who underwent cardiac computed tomography, LVOTAbiplane had better agreement with LVOTA by direct planimetry than LVOTAcirc (mean bias, -0.45±0.63 vs -1.02±0.63cm2; P<.0001). Of 82 patients with severe AS (AVA≤1cm2 using LVOTAcirc), 40 (49%) had discordant mean gradient (<40mm Hg). By using LVOTAbiplane, patients with discordant AVA and mean gradient decreased from 49% to 27% (P=.004), and 29% of patients with severe AS were reclassified with moderate AS, with the highest percentage of reclassification in the group with low-gradient AS with preserved left ventricular ejection fraction. Direct planimetry using biplane imaging avoids the inherent underestimation of LVOTA using the circular assumption. LVOTA obtained by biplane planimetry can lead to better concordance between AVA and mean gradient and classification of AS severity.

The evaluation of aortic stenosis, how the new guidelines are implemented across Europe: a survey by EACVI.

Aortic stenosis (AS) is the most prevalent valvular disease in developed countries, with a prevalence that is set to expand further with an ageing population. The most recent guidelines on valvular heart disease published by the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery, aim to standardize the diagnosis and management of valvular heart diseases. The imaging criteria of the current guidelines are mostly based on EACVI Recommendations, with an appropriate diagnostic workflow being of major importance, to ensure streamlined and efficient patient assessment and accurate diagnoses and decisions regarding the timing of surgery. The EACVI Scientific Initiatives Committee, therefore, created a survey on the imaging assessment of patient with AS to investigate the diagnostic patient pathways used in different centres across Europe. In particular, we conducted this survey to better understand the use and access of advanced imaging techniques in AS including 3D transthoracic echocardiography and 3D transoesophageal echocardiography, cardiac computed tomography, and cardiovascular magnetic resonance.

The Association between Aortic Valve Weight, Echocardiographic Indices, and All-Cause Death in 1,046 Patients Undergoing Surgical Aortic Valve Replacement for Aortic Stenosis

Background: Aortic valve weight (AVW), a flow independent measure of aortic stenosis (AS) severity, is reported to have heterogeneous associations with the echocardiographic variables used for AS evaluation. Controversy exists regarding its impact on survival after aortic valve replacement (AVR). Objective: We sought to determine the association between AVW with echocardiographic measures of AS severity and all-cause mortality after surgical AVR. Methods: One thousand and forty-sixconsecutive patients underwent surgical AVR for AS, the excised valves were weighed, and an echocardiogram was done before surgery. Results: Males had heavier valves than females, for both absolute and body surface are (BSA)-indexed values (2.78 ± 1.23 vs. 2.08 ± 0.68 g, p < 0.001; and 1.38 ± 0.61 vs. 1.19 ± 0.41 g/m², p < 0.001, respectively). In a restricted cohort of 634 patients with isolated severe AS and normal ejection fraction, the correlations of AVW with echocardiographic variables of AS were modest, the strongest being with the dimensionless index (r = –0.27 and –0.26 for male and female, both p < 0.01). Stratified by stroke volume index and mean gradient (MG), no associations were found in the low-gradient groups (i.e., MG <40 mmHg). At a median follow-up of 3.5 years, there were only 244 deaths in the entire cohort. Mortality was not related to AVW, except in females who displayed an inverse relationship (HR = 0.67; 95% CI 0.47–0.95) only when it was analyzed as a continuous variable. Conclusions: The weak correlation between AVW with the echocardiographic indices of AS may reflect its complex pathophysiology, heterogeneous hemodynamics, and possible pitfalls in the current echocardiographic methods used in clinical practice. The prognostic value of AVW after AVR warrants further evaluation.

Aortic-valve calcium score for the diagnosis of severe aortic stenosis: A systematic review and meta-analysis

Aortic stenosis (AS) is the most common valvular disease. Nowadays, the degenerative process including valve calcification is the main etiology. Severe AS is associated with poor prognosis and is an indication for aortic-valve intervention. While echocardiography is the main imaging tool to diagnose and quantify AS severity, computed tomography can also be used in difficult cases, and the aortic-valve calcification score is proposed as a proxy to quantify the disease severity. Nevertheless, different thresholds are proposed to grade AS. We performed systematic review and meta-analysis of studies using computed tomography to diagnose severe AS. Up to 30/11/2018, the key terms “aortic-valve”, “stenosis”, “computed tomography”, “calcification” or “calcium” were searched in PubMed. Our predefined inclusion criteria were clinical studies to diagnose severe AS by aortic-valve calcification derived from computed tomography. Studies including only native valves and providing cut-off levels for stenosis severity were included. The Agatston method were used and expressed in Agatston unit. Eleven from 534 studies, including 4,529 patients, were eligible. Population, AS severity, acquisition modalities and results were heterogenous. Aortic-valve calcification score was accurate to diagnose severe AS (pooled area under the curve = 0.89 ± 0.02). The cut-off levels differed between studies. With meta-analysis, the optimal cut-off was 1,648 AU for general population. Only three studies provided a cut-off per gender, with optimal value derived from meta-analysis of 1,354 AU for women and 2,048 AU for men. Aortic-valve calcification score derived from computed tomography is useful to diagnose severe AS. It can provide supplementary data for evaluation of AS in patients with discordant echocardiographic findings. However, individual participant data meta-analysis is required to identify the most appropriate cut-off values with better accuracy.