Asymptomatic Aortic Stenosis Research Articles

Abstract 9493: Differences in Prognostic Implications of Changes in Echocardiography in Asymptomatic Severe Aortic Stenosis Managed Conservatively

Background: No previous study has explored the association between the changes in echocardiographic parameters during follow-up and clinical outcomes in patients with asymptomatic severe aortic stenosis (AS) and who were managed conservatively. Objective: This study aimed to investigate the prognostic impact of the changes in echocardiographic parameter at 1-year follow-up in asymptomatic severe AS patients managed conservatively. Methods: Among 3815 patients with severe AS enrolled in the multicenter CURRENT AS registry in Japan, we analyzed conservatively managed 555 patients who underwent echocardiography at 1-year follow-up and remained asymptomatic. The primary outcome measure was a composite of AS-related deaths and hospitalization due to heart failure. A decline in left ventricular ejection fraction (LVEF), an increase in left ventricular end-diastolic dimension (LVEDD), and an increase in aortic valve pressure gradient (PG) were defined as above 10%, 5mm, and 30mmHg, respectively, based on the clinically relevant values. Results: There were 61 patients (11.0 %) with >10% decline in LVEF and 494 patients (89.0%) without decline. The cumulative 3-year incidence of the primary outcome measure was significantly higher in the decline in LVEF group than in no decline in LVEF group. After adjusting for confounders, the excess risk of the decline in LVEF relative to no decline in LVEF for the primary outcome measure remained significant (hazard ratio; 2.76, 95% confidence interval 1.66-4.45). The cumulative 3-year incidence of the primary outcome measure was significantly higher in the increase in LVEDD group than in no increase in LVEDD group. In contrast, there were no difference in cumulative 3-year incidence of the primary outcome measure between the increase in aortic valve PG and no increase group. Conclusions: Severe asymptomatic AS patients with a >10% LVEF decline or >5mm increase in LVEDD at 1-year after diagnosis had worse AS-related clinical outcome than those without under conservative management, whereas there were no differences in the outcomes stratified by changes in aortic valve PG. This indicated the importance in the LV morphology and function during follow-up in asymptomatic severe AS patients when managed conservatively.

Myocardial efficiency in patients with different aetiologies and stages of heart failure.

Myocardial external efficiency (MEE) is the ratio of cardiac work in relation with energy expenditure. We studied MEE in patients with different aetiologies and stages of heart failure (HF) to discover the role and causes of deranged MEE. In addition, we explored the impact of patient characteristics such as sex, body mass index (BMI), and age on myocardial energetics. Cardiac energetic profiles were assessed with 11C-acetate positron emission tomography (PET) and left ventricular ejection fraction (LVEF) was acquired with echocardiography. MEE was studied in 121 participants: healthy controls (n = 20); HF patients with reduced (HFrEF; n = 25) and mildly reduced (HFmrEF; n = 23) LVEF; and patients with asymptomatic (AS-asymp; n = 38) and symptomatic (AS-symp; n = 15) aortic stenosis (AS). Reduced MEE coincided with symptoms of HF irrespective of aetiology and declined in tandem with deteriorating LVEF. Patients with AS-symp and HFmrEF had reduced MEE as compared with controls (22.2 ± 4.9%, P = 0.041 and 20.0 ± 4.2%, P < 0.001 vs. 26.1 ± 5.8% in controls) and a further decline was observed in patients with HFrEF (14.7 ± 6.3%, P < 0.001). Disproportionate left ventricular hypertrophy was a major cause of reduced MEE. Female sex (P < 0.001), a lower BMI (P = 0.001), and advanced age (P = 0.03) were associated with a lower MEE. MEE was reduced in patients with HFrEF, HFmrEF, and HF due to pressure overload and MEE may therefore constitute a treatment target in HF. Patients with LVH, advanced age, female sex, and low BMI had more pronounced reduction in MEE and personalized treatment within these patient subgroups could be relevant.

Cause of Death After Surgical Aortic Valve Replacement: SWEDEHEART Observational Study.

BackgroundPrior studies showed that life expectancy in patients who underwent surgical aortic valve replacement (AVR) was lower than in the general population. Explanations for this shorter life expectancy are unknown. The aim of this nationwide, observational cohort study was to investigate the cause‐specific death following surgical AVR.Methods and ResultsWe included 33 018 patients who underwent primary surgical AVR in Sweden between 1997 and 2018, with or without coronary artery bypass grafting. The SWEDEHEART (Swedish Web‐System for Enhancement and Development of Evidence‐Based Care in Heart Disease Evaluated According to Recommended Therapies) register and other national health‐data registers were used to obtain and characterize the study cohort and to identify causes of death, categorized as cardiovascular mortality, cancer mortality, or other causes of death. The relative risks for cause‐specific mortality in patients who underwent AVR compared with the general population are presented as standardized mortality ratios. During a mean follow‐up period of 7.3 years (maximum 22.0 years), 14 237 (43%) patients died. The cumulative incidence of death from cardiovascular, cancer‐related, or other causes was 23.5%, 8.3%, and 11.6%, respectively, at 10 years, and 42.8%, 12.8%, and 23.8%, respectively, at 20 years. Standardized mortality ratios for cardiovascular, cancer‐related, and other causes of death were 1.79 (95% CI, 1.75–1.83), 1.00 (95% CI, 0.97–1.04), and 1.08 (95% CI, 1.05–1.12), respectively.ConclusionsWe found that life expectancy following AVR was lower than in the general population. Lower survival after AVR was explained by an increased relative risk of cardiovascular death. Future studies should focus on the role of earlier surgery in patients with asymptomatic aortic stenosis and on optimizing treatment and follow‐up after AVR.RegistrationURL: https://www.clinicaltrials.gov; Unique identifier: NCT02276950.

Left atrial volume index predicts adverse events in asymptomatic moderate or severe aortic stenosis.

In aortic stenosis (AS), chronic pressure overload on left ventricle (LV) leads to LV hypertrophy, impaired relaxation, increased chamber stiffness, fibrosis and left atrial (LA) dilatation. An enlarged LA may be a marker of longstanding diastolic dysfunction (DD) and more advanced disease in AS. We aimed to assess the impact of LA volume index (LAVI) on events in patients with moderate or severe AS. A total of 324 patients (mean age 69±13 years, 61% men) were included. LA volume was measured by biplane Simpson's method using apical four- and two-chamber views and indexed to body surface area. An increased LAVI was defined as>34ml/m2 . The mean EF was 64±8%, LAVI 35±14ml/m2 and flow rate 244±70ml/s. The number of total events was 275 (85%): 243 (75%) aortic valve replacement and 32 (10%) deaths. Mean follow-up 23.7±23.8 months (median 15.2 months). An increased LAVI (45% [n=145]) was associated with adverse events (HR 1.86; 95% CI 1.24-2.82, p=0.003) independent of age, smoking, diabetes, atrial fibrillation, LV ejection fraction, LV mass, aortic valve area, and low flow rate (<200ml/s). In the same multivariate model, when increased LAVI was replaced by E/e' ratio ≥14cm, no association was found between E/e' ratio ≥14cm and adverse events (HR 1.18; 95% CI .78-1.78, p=0.430). LAVI was an independent predictor of adverse events in patients with moderate or severe AS and preserved ejection fraction. Including LAVI in the risk assessment of AS patients may further improve risk stratification.

Left atrial dynamics in the hemodynamic response during exercise in patients with asymptomatic severe aortic stenosis

Abstract Background The hemodynamic impact of left atrial (LA) dynamics in aortic stenosis (AS) in relation to cardiopulmonary response to exercise has never been studied. We aimed at investigating the link between LA function vs hemodynamics and prognosis in asymptomatic severe AS patients. Methods A total of 106 patients: 76 asymptomatic severe AS patients (aortic valve area (AVA) &amp;lt;1.0 cm2 or AVA index &amp;lt;0.6 cm2/m2) and 30 gender-matched control subjects underwent cardiopulmonary exercise testing combined with Echo-Doppler with assessment of LA strain. AS patients were divided into 4 groups according to peak aortic jet velocity (PV), mean pressure gradient (MPG), stroke volume index (SVI), and left ventricular ejection fraction (LVEF). Results Normal-flow low-gradient AS (NFLG: PV &amp;lt;4 m/s and MPG &amp;lt;40 mmHg, SVI &amp;gt;35ml/m2, LVEF ≥50%, N=23), High-gradient AS (HG: PV ≥4 m/s or MPG ≥40 mmHg, LVEF ≥50%, N=23), Paradoxical low-flow low-gradient AS (PLFLG: PV &amp;lt;4 m/s and MPG &amp;lt;40 mmHg, SVI ≤35ml/m2, LVEF ≥50%, N=18), and Classical low-flow AS (CLF: LVEF &amp;lt;50%, N=12) had a higher LA volume index than Control (Control 22±6, NFLG 38±12*, HG 33±9*, PLFLG 33±11*, and CLF 49±15* ml/m2, *P&amp;lt;0.05 vs Control). In PLFLG and NFLG AS, LA strain at rest (21±9 and 26±13%) and during exercise (26±12 and 31±14%) were decreased compared to Control (37±8% at rest, 43±11% during exercise) but LA strain was increased from rest to exercise (P&amp;lt;0.001). HG and CLF AS had no increase in LA strain (31±15 and 19±10% at rest, 28±15 and 18±9% during exercise) (figure). In Cox proportional hazards analysis, age and gender adjusted hazard ratio for the composite end point (aortic valve replacement, hospitalization for heart failure, and all-cause mortality) of changes in LA-strain from rest to exercise (1% increase) was 1.05 (95% CI 1.00 to 1.09, P=0.044) among AS patients. Conclusions In asymptomatic severe AS, the study of LA functional adaptation to exercise plays a key role in the hemodynamic unfavorable cascade signaling major adaptive differences in dynamics during physical challenge. Overall, LA dynamics provides prognostic information also in AS patients. Funding Acknowledgement Type of funding sources: None.

Mechanoenergetic coupling in heart failure with preserved, mid-range and reduced left ventricular ejection fraction

Abstract Background Heart failure (HF) classification based on left ventricular ejection fraction (LVEF) can vary because of changes in filling pressures, afterload, and contractile function. 11C-acetate positron emission tomography (PET) provides a load-independent measure of myocardial external efficiency (MEE) by simultaneous assessment of myocardial oxygen consumption (MVO2), cardiac work, left ventricular mass (LVM), end-systolic wall stress (ESWS), and myocardial blood flow (MBF). Purpose We aimed to characterize mechanoenergetic derangements in patients with HF and to study its interrelation with age, sex and obesity. Methods MEE was measured in 121 participants with 11C-acetate PET, and LVEF was acquired with echocardiography. We investigated healthy controls (n=20) and patients with HF and reduced LVEF &amp;lt;40% (HFrEF; n=25), mid-range LVEF 40–49% (HFmrEF; n=23), as well as patients with asymptomatic aortic valve stenosis (AS) and LVEF ≥50% (AS-asymp; n=38), and symptomatic AS and LVEF ≥50% (defined as HF with preserved LVEF (HFpEF); n=15). Results MEE declined in tandem with reduced LVEF from HFpEF and HFmrEF to HFrEF (p=0.041, p&amp;lt;0.001, and p&amp;lt;0.001 versus control, respectively; Figure 1). Impaired MEE was aggravated with increasing LVM (p=0.001) due to a disproportionate increase in overall left ventricular MVO2. In a multivariate analysis, female sex (p&amp;lt;0.001), a lower body mass index (p&amp;lt;0.001), and advanced age (p=0.01) were associated with a lower MEE (Figure 2). HFpEF, HFmrEF, and HFrEF patients had distinct energetic profiles involving MEE, MVO2, MBF, ESWS, and LVM (Figure 2). Conclusions Mechanoenergetic uncoupling was evident in every clinical state within the HF syndrome and associated with left ventricular hypertrophy and progressive systolic dysfunction. Sex, age, and obesity impacted myocardial energetics. To date, the present study is the largest investigation of mechanoenergetic coupling across several categories of patients with heart failure. 11C-acetate PET extends our pathophysiological comprehension of the HF syndrome beyond LVEF. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): The Danish Heart FoundationThe Lundbeck Foundation Relationship between LVEF and MEEMyocardial energetics in heart failure

Role of Exercise Testing and Speckle Tracking Echocardiography in Paradoxical Severe Aortic Stenosis.

IntroductionThe clinical behavior and prognosis of patients with asymptomatic paradoxical low-gradient aortic stenosis (PLGAS) still remain controversial. Some authors consider PLGAS as an echocardiographically poorly quantified moderate AS (MAS). We aimed to investigate the clinical behavior of PLGAS by comparing it with that of asymptomatic high-gradient aortic stenosis (HG-AS) and MAS using transthoracic echocardiography (TTE) with speckle tracking imaging (STI) and cardiopulmonary exercise testing (CPET). The hypothesis of our study is, unlike that described by other authors, to demonstrate the existence of clinical and echocardiographic differences between PLGAS and MAS.MethodsA cohort of 113 patients was included and categorized into three groups according to AS type: MAS (n=63), HG-AS (n=29), and PLGAS (n=21). Patients’ clinical data were obtained. Patients underwent 2D TTE with STI and CPET.ResultsThere were no significant differences in the clinical variables between the three AS groups. In the multivariate multinomial logistic regression analysis, with PLGAS being the reference category, the most powerful variable for establishing a difference with HG-AS was the left ventricular mass (LVM) indexed by body-surface area (odds ratio [OR]=1.04, confidence interval (CI)=1.01-1.06, p<0.05). The MAS group showed less abnormal CPET (OR=0.198, CI=0.06-0.69, p<0.05), and higher left ventricle global longitudinal strain rate (GLSR) (OR=0.003, CI=0.00-0.35, p<0.05) than the PLGAS group.ConclusionsTTE with STI and CPET established the clear differences between patients with asymptomatic PLGAS and those with asymptomatic MAS, as well as the similarities between patients with PLGAS and those with HG-AS. Our data identify PLGAS as a completely different entity from MAS.

Severe asymptomatic aortic stenosis: management of a patient

Severe asymptomatic aortic stenosis: management of a patient

Comparison of Outcomes of Asymptomatic Moderate Aortic Stenosis With Preserved Left Ventricular Ejection Fraction in Patients ≥80 Years Versus 70-79 Years Versus

Aortic stenosis (AS) is increasingly diagnosed in the aging population with more studies focused on the prognostic outcomes of severe asymptomatic AS. However, little is known about the outcomes of moderate asymptomatic AS in the elderly population. From 2001 to 2020, 738 consecutive patients with asymptomatic moderate AS with preserved left ventricular ejection fraction were studied. They were allocated according to the age group at the index echocardiography: very elderly (≥80 years), elderly (70 to 79 years) and control group (<70 years). The primary study outcomes were aortic valve replacement (AVR), congestive cardiac failure (CCF) and all-cause mortality. Overall, about one-third of the subjects were in the very elderly, elderly and control groups each. The median follow-up duration was 114.2 (interquartile range, 27.0 to 183.7) months. There was significantly higher all-cause mortality in the very elderly group (47.9%) followed by elderly (34.8%) and control group (21.9%). Similarly, there was significantly higher CCF rates in the very elderly group (5.8%) compared to elderly (5.1%) and control group (2.8%). There were significantly lower rates of AVR offered and completed in the very elderly group compared to control group. Multivariable logistic regression demonstrated that age ≥80 years remained an independent predictor of mortality after adjusting for important prognostic cofounders (Adjusted HR 2.424, 95% CI 1.728 to 3.400, p < 0.001). Cox regression showed no significant difference in mortality between patients ≥80 years with moderate AS compared to a younger age-group ≥70 years with severe AS. In conclusion, very elderly patients of ≥80 years of age with moderate AS have worse prognostic outcomes than their younger counterparts. They share similar unfavorable prognostic outcomes as those of a younger age-group ≥70 years with severe AS. Closer surveillance are warranted in this group of at-risk elderly patients.

Plasmatic PCSK9 Levels Are Associated with Very Fast Progression of Asymptomatic Degenerative Aortic Stenosis

The aim of this work was to study the association of potential biomarkers with fast aortic stenosis (AS) progression. Patients with moderate-to-severe AS were classified as very fast progressors (VFP) if exhibited an annualized change in peak velocity (aΔVmax) ≥0.45m/s/year and/or in aortic valve area (aΔAVA) ≥-0.2cm2/year. Respective cut-off values of ≥0.3m/s/year and ≥-0.1cm2/year defined fast progressors (FP), whereas the remaining patients were non-fast progressors (non-FP). Baseline markers of lipid metabolism, inflammation, and cardiac overload were determined. Two hundred and nine patients (97 non-FP, 38 FP, and 74 VFP) were included. PCSK9 levels were significantly associated with VFP (OR 1.014 [95%CI 1.005-1.024], for every 10 ng/mL), as were active smoking (OR 3.48) and body mass index (BMI, OR 1.09), with an AUC of 0.704 for the model. PCSK9 levels, active smoking, and BMI were associated with very fast AS progression in our series, suggesting that inflammation and calcification participate in disease progression.

Low myocardial energetic efficiency is associated with increased mortality in aortic stenosis

ObjectivesIn hypertension, low myocardial energetic efficiency (MEEi) has been documented as an integrated marker of metabolic and left ventricular (LV) myocardial dysfunction. We tested the predictive performance of MEEi in...

Literature review on the risk assessment and timing of aortic valve replacement for asymptomatic severe aortic stenosis

钙化性主动脉瓣狭窄（CAS）是目前最常见的一种可能需要外科手术或导管介入干预的原发性瓣膜疾病，因缺乏有效的药物干预手段，大多数CAS患者会逐渐进展为重度主动脉瓣狭窄（SAS）。在临床实践中，有许多SAS患者处于无症状期，其中有些患者病情进展快速，预后较差。现行的心脏瓣膜病管理指南推荐对所有无症状SAS患者进行风险评估，低风险患者可密切临床随访，而高风险患者应尽早接受主动脉瓣置换术（AVR）以降低死亡率和不良心血管事件的发生率，因此明确风险评估的方法和确定行AVR的时机对于无症状SAS患者的诊疗至关重要。本文就无症状SAS患者的风险评估及其行AVR的时机进行简要综述。.

Optimal Threshold of Left Ventricular Ejection Fraction for Aortic Valve Replacement in Asymptomatic Severe Aortic Stenosis: A Systematic Review and Meta-Analysis.

BackgroundThe optimal threshold of left ventricular ejection fraction (LVEF) that should prompt aortic valve replacement (AVR) in asymptomatic patients with high‐gradient severe aortic stenosis (AS) is controversial. The aim of this study was to assess the relationship between LVEF and mortality benefit in comparing early AVR versus watchful waiting in asymptomatic patients with severe AS.Methods and ResultsMEDLINE, Embase, Web of Science, and Google Scholar were searched for observational studies and randomized controlled trials on adults with asymptomatic severe AS. Severe AS was defined by a peak aortic velocity ≥4 m/s and/or mean aortic valve gradient ≥40 mm Hg and/or calculated aortic valve area <1.0 cm2 or an indexed valve area <0.6 cm2. Studies comparing AVR with conservative management were included and meta‐analysis on all‐cause mortality was performed. Ten eligible studies were identified with a total of 3332 patients. In 5 observational studies comparing early AVR versus watchful waiting, our meta‐analysis showed early AVR was associated with lower mortality with a hazard ratio (HR) of 0.41 (CI, 0.23–0.71; P<0.01). In 4 observational studies comparing AVR versus no AVR, our meta‐analysis showed AVR was associated with lower mortality with a HR of 0.31 (CI, 0.17–0.58; P<0.001). In a meta‐regression analysis pooling all 10 studies, there was no statistically significant correlation between study mean LVEF and the size of mortality benefit of AVR (P=0.83).ConclusionsAmong asymptomatic patients with high‐gradient severe AS, AVR was associated with a mortality benefit across the spectrum of LVEF. Our study calls into question the need of an LVEF threshold for recommending AVR in this patient population.

Exercise test in patients with asymptomatic aortic stenosis – clinically useful or not?

Aortic valve replacement (AVR) is recommended for symptomatic patients with severe aortic stenosis (AS). In asymptomatic AS (AAS), exercise testing (ET) is recommended; however, it remains controversial. The aim of our study was to assess the importance of ET in patients with AAS. A total of 89 patients with AAS (53 men; mean [SD] age, 59.5 [11.7] years) underwent 244 symptom‑limited ETs. All ETs were clinically negative. During the median (interquartile range) follow‑up of 22 (12) months, 39 patients (22 men) developed symptoms (the AVR group). This group was compared with 50 asymptomatic non‑AVR patients. In the multivariable Cox analysis, the maximal heart rate during ET less than 85% of age- and sex-adjusted maximal predicted heart rate (THR less than 85%) was related to AVR (P = 0.01). After adjusting for the use of β‑blockers, this was not significant (P = 0.08). In the β‑blocker subgroup, the THR less than 85% was significantly related to AVR in the univariable Cox analysis (hazard ratio, 2.2; 95% CI, 1.07-4.9; P = 0.03) and after adjusting for age (P = 0.047). This relationship was not observed in patients who did not receive β‑blockers. In patients with AAS, ET is safe; however, in our study group, the results were not cru‑ cial in making a decision to perform AVR. Patients treated with β‑blockers who did not achieve 85% of predicted maximal heart rate had a higher probability of AVR. The influence of the use of β‑blockers on the decision to perform AVR in this patient population warrants further revision.

Prognostic value of contractile reserve evaluated by global longitudinal strain in patients with asymptomatic severe aortic stenosis

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Investigaciones Médicas. Cardiodiagnóstico. Buenos Aires Introduction. Left ventricle Global Longitudinal Strain(GLS) at rest has shown prognostic value in patients(pts) with severe aortic stenosis(SAS). Contractile reserve(CR) during exercise stress echo(ESE) estimated by GLS(CR-GLS) could better stratify the asymptomatic patients who could benefit from early intervention. Objective. To establish the long-term prognostic value of CR-GLS in pts with asymptomatic SAS during ESE. Secondly, to compare if the CR evaluated by ejection fraction(CR-EF) presented similar results to those of CR-GLS. Methodology. In a single center, prospective study carried out between May 2013 to Oct 2019, we enrolled 101 pts(69 ± 12 years,54 men) with asymptomatic SAS(aortic valve area &amp;lt; 0,6cm2/m2) and preserved EF(&amp;gt;55%). GLS value was considered as the average of the 16 segments, obtained from the apical views of 3, 4 and 2 chambers at rest and peak ESE. CR was considered present with stress-rest increase of &amp;gt;5points with EF and &amp;gt;2 absolute points by GLS. The pts were divided into 2 groups(G): G1:Pts with presence of CR-GLS and G2:Pts with absence of CR-GLS. Major cardiovascular event was considered to be: need for valve replacement due to the presence of symptoms, death, acute myocardial infarction and stroke. All patients were followed-up. Results. Of the 101 pts analyzed, 56pts(55.4%) were included in G1(CR-GLS) and 45pts(44.6%) in G2(no CR-GLS). The G2 patients were older(G2 72.2 ± 8.5 vs G1 66.5 ± 14.1) with lower METS(G1 5.6 ± 2 vs G2 4.2 ± 1.1,p 0.004), a higher percentage of flat blood pressure response(G1 19.6% vs. G2 37.8%,p 0.036), lower peak EF(G1 71.5%±5.8 vs G2 66.8 ± 7.9,p0.001),peak GLS(G1 -22.2%±2.8 vs G2 -18.45%±2.4 p 0.001) and lower ΔGLSstress-rest(G1 GLS 3.07 ± 0.85 vs G2 0.08 ± 1.9 p 0.003). The same behaviour with the EF response(G1 7.32 ± 2.9 vs G2 4.7 ± 5.3,p 0.024). The average follow-up was 46.6 ± 3.4 months, and events occurred in 45 patients: 12 all-cause deaths(9 cardiac), 31 valve replacement, 1 myocardial infarctions, 1 strokes. G2 pts had more events compared to G1 pts (G2 = 26 events 57.8% vs G1 = 19 events 42.2%,p &amp;lt; 0.01)(figure 1). The CR-EF did not separate patients with and without events. At Cox analysis, CR-GLS was the only predictor variable of major events(HR:1.97, 95% CI 1.09-3.58)p &amp;lt; 0.025). Conclusions In patients with asymptomatic SAS, the absence of CR-GLS during ESE identifies a group of patients with a worse prognosis and the need for aotic valve intervention. CR-GLS proved to be superior tan CR-EF. Baselin characteristic between groups Abstract Figure. Left ventricle RC-GLS and survival

Asymptomatic severe aortic stenosis: what is the current role of exercise stress test and NT-proBNP in patient risk stratification

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Aortic stenosis (AS) is prevalent in the elderly population. When severe and the patient is symptomatic or left ventricular dysfunction arises, the prognosis deteriorates and valve replacement (AVR) is recommended. During the asymptomatic phase regular clinical evaluation is advised to detect early onset of symptoms and/or signs of myocardial maladaptation. Due to the inherent difficulties in the evaluation of symptoms, especially in the elderly, as well as the change in prognosis when symptoms appear (even if not perceived), it is crucial to evaluate the behavior of patients with effort and signs of myocardial injury. Methods An observational and retrospective study that included 74 patients followed at the Cardiology Service by severe AS (aortic valve area ≤ 1cm2 and/or aortic transvalvular mean gradient ≥40mmHg), who underwent exercise stress test (EST) and NT-proBNP evaluation for risk stratification. The outcome studied was hospitalization for heart failure (HF), or referral to SV, or death during the follow-up period. Independent predictors were obtained using multivariate Cox regression. Results Non-progression or decrease in systolic blood pressure (SBP) in EST is the only independent predictor of a short-term adverse event (p = 0.025). This parameter, NT-proBNP levels and interventricular septal thickness (IVS) were independent predictors of a medium (two (p = 0.025; p = 0.014; p = &amp;lt;0.001), three (p = 0.015; p = 0.007; p = 0.001) and four years (p = 0.007; p = 0.049; p = 0.005)) and a long term adverse event (p = 0.006; p = 0.028; p = 0.005). Conclusion In asymptomatic patients with severe AS, no progression or decrease in SBP in EST, increased NT-proBNP levels and thickness of IVS were independent predictors of hospitalization for HF, need for VS or death in short, medium and long term.

The first-phase ejection fraction - association with outcome in aortic valve stenosis

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Danish Heart Association. Background First-phase ejection fraction (EF1), the ejection fraction (EF) until the time of peak systolic flow may be a sensitive marker of subclinical left ventricular (LV) dysfunction. This study investigated the prognostic value of EF1 in asymptomatic and symptomatic severe aortic stenosis (AS). Methods This study included 94 asymptomatic and 108 symptomatic patients with severe AS. The prognostic value of EF1 was compared with other echocardiographic markers and magnetic resonance imaging (MRI) measured end-systolic wall stress and late gadolinium enhancement fibrosis (LGE). Asymptomatic patients were followed up for 3.0 years (primary outcome death or aortic valve replacement). Symptomatic patients were followed up for 4.3 years (primary outcome death). Results In multivariate regression analysis wall stress (p &amp;lt; 0.001) and LGE (p = 0.03) were associated with EF1. In the asymptomatic cohort EF1 was significantly associated with the end-point, especially among the subgroup of patients with a mean gradient &amp;lt; 40 mmHg (HR 0.91, p = 0.005), while global longitudinal strain was not. In the surgical cohort, EF1 was borderline associated with death (p = 0.08) which was significant after correction for LGE (HR 0.90, p = 0.02). Conclusion EF1 is a predictor of death or AVR in asymptomatic AS, especially among discordantly graded patients with low area and low gradient. Univariate β (95% CI) p-value Multivariate β (95% CI) p-value Age (years) .03 (-.09 to .16) 0.58 .03 (-.12 to .18) 0.69 Sex (male) -.12 (-2.26 to 2.03) 0.91 .24 (-2.31 to 2.80) 0.85 Hypertension -.08 (-2.22 to 2.07) 0.95 Aortic valve area (0.01 cm2) .09 (.04 to .14) 0.001 Aortic mean gradient (mmHg) -.02 (-.08 to .04) 0.56 LV end-diastolic volume (ml) -.07 (-.11 to -.03) &amp;lt;0.001 LV end-systolic volume (ml) -.17 (-.22 to -.12) &amp;lt;0.001 -.07 (-.15 to .02) 0.11 LV ejection fraction (%) .28 (.19 to .38) &amp;lt;0.001 LV peak ejection time (ms) -.07 (-.16 to .02) 0.13 LGE fibrosis -3.04 (-5.67 to -.42) 0.02 -2.64 (-4.99 to -.30) 0.03 Wall stress (kdynes/m3) -.10 (-.13 to -.08) &amp;lt;0.001 -.08 (-.12 to -.04) &amp;lt;0.001 Multivariate linear regression analysis for associations with first phase ejection fraction. LV is left ventricular, LGE late gadolinium enhancement Abstract Figure. AVR-free survival according to EF1

Transcatheter Aortic Valve Implantation During the COVID-19 Pandemic

Transcatheter aortic valve implantation (TAVI) outcomes during the coronavirus disease 2019 (COVID-19) pandemic have not been fully evaluated and some structural programs in the world have been suspended during this period. We sought to evaluate and compare clinical outcomes in patients undergoing TAVI in pandemic versus nonpandemic era. In a single center, we compared 198 TAVI patients performed during 2019 to 59 patients performed during the COVID-19 pandemic period (March 1st to June 30th, 2020). Primary outcome was procedural success according to VARC criteria and 30-day mortality rates. VARC-defined procedural success was high in both groups (93.3% vs 96.6%; p = 0.53). There were no differences in any vascular complications (26% vs 19%; p = 0.3), permanent pacemaker implantation (11.8% vs 15.3%; p = 0.63), and length of hospital stay (5.2 vs 4.2 days; p = 0.29). Thirty-day mortality was similar (3% vs 3.4%; p = 1.0). We had no documented COVID-19 disease in our patients during follow up. In conclusion, TAVI procedures can be performed effectively and safely during the COVID-9 pandemic, using a minimalist approach, early discharge, and by maintaining proper use of personal protective equipment.

Evaluation of the Effect of Aortic Stenosis and Severity on Left Ventricular Function by Isovolumic Myocardial Acceleration

Aim: Tissue Doppler-derived isovolumic acceleration (IVA) is a parameter that evaluates the systolic function of both ventricles, without being affected by pre-load and post-load. We aimed to detect left ventricular systolic dysfunction at an early stage with IVA in patients with asymptomatic aortic stenosis (AS).&#x0D; Material and Methods: A total of 105 patients were included in the study, 75 of which had isolated AS and 30 were free of any valve disease. Patients with AS were divided into three groups (mild, moderate and severe) according to their aortic valve area (AVA) and aortic peak velocities, as determined by means of a transthoracic echocardiography. Conventional echocardiography, systolic and diastolic Tissue Doppler parameters [peak myocardial velocity during isovolumic contraction (IVV), myocardial velocity during ejection phase (Sm), early diastolic myocardial velocity (e'), late diastolic myocardial velocity (a'), and acceleration time (AT)] were calculated in all patients. IVA was obtained by dividing the IVV flow rate by the AT time.&#x0D; Results: The systolic parameters IVV (p

Prognostic value of automated longitudinal strain measurements in asymptomatic aortic stenosis

ObjectiveTwo-dimensional (2D) longitudinal strain (LS) predicts cardiac events in aortic stenosis (AS). However, it requires manual editing, which affects its accuracy and reliability. We investigated whether left ventricular (LV), left...