Mixed Aortic Valve Disease Research Articles

Commentator Discussion: Five-year comparison of clinical and echocardiographic outcomes of pure aortic stenosis with pure aortic regurgitation or mixed aortic valve disease in the COMMENCE trial

Commentator Discussion: Five-year comparison of clinical and echocardiographic outcomes of pure aortic stenosis with pure aortic regurgitation or mixed aortic valve disease in the COMMENCE trial

A Case Report On Metoprolol Induced Nightmares And Hallucinations

Metoprolol is a cardioselective beta-1-adrenergic blocker. It is frequently prescribed for cardiovascular conditions but is associated with potential central nervous system adverse effects, including hallucinations and nightmares. We discuss the case of an 84-year-old female with mixed aortic valve disease who experienced hallucinations and nightmares after starting metoprolol medication. Her symptoms improved after she stopped using metoprolol, indicating a likely causative link. This example emphasizes the significance of rapidly diagnosing and addressing adverse medication reactions, especially in elderly patients who may have underreported symptoms. Understanding the pharmacological properties of lipophilic beta-blockers and their effects on neurological function is critical for improving patient care and reducing negative outcomes

Alterations in Left Atrial and Ventricular Coupling in Mixed Aortic Valve Disease.

To characterize left atrial (LA) and left ventricular (LV) function and atrioventricular (AV) coupling in patients with moderate mixed aortic valve disease (MMAVD) against those with isolated moderate or severe aortic valve disease and controls. Retrospective LA and LV peak longitudinal strain (LS) analysis were performed on 260 patients (46 MMAVD, 81 moderate aortic stenosis (AS), 50 severe AS, 48 moderate aortic regurgitation (AR), and 35 severe AR) and 66 controls. Peak LV and LA LS and AV coupling, assessed by combined peak LA and LV strain, was compared between the groups. ANOVA and 2-sided t-tests were used and a p-value of <0.01 was considered significant.LV strain was significantly lower in those with MMAVD compared to controls and those with moderate or severe isolated AR but comparable to those with moderate or severe AS (-17.1±1.1% MMAVD vs. -17.7±1.5% moderate AS p=0.02; vs. -17.0%±1.5% severe AS, p=0.74). AV coupling was significantly lower in those with MMAVD compared to controls and those with moderate AS or AR but comparable to those with severe AS or AR (47.1±6.8% MMAVD vs. 45.1±5.6% severe AS, p=0.13; vs. 50.4±9% severe AR, p=0.07). Impairments in AV coupling are comparable for patients with MMAVD and those with severe isolated AS or AR. Impairments in LV GLS in MMAVD mirror those found in severe AS. These findings suggest that haemodynamic consequences and adverse remodelling are similar for patients with MMAVD and isolated severe disease.

Mixed aortic valve disease: association with paravalvular leak and reduced survival after transcatheter aortic valve replacement.

Transcatheter aortic valve replacement (TAVR) revolutionized the therapy of severe aortic stenosis (AS) with rising numbers. Mixed aortic valve disease (MAVD) treated by TAVR is gaining more interest, as those patients represent a more complex cohort as compared with isolated AS. However, concerning long-term outcome for this cohort only, limited data are available. The aim of the study is to assess the prevalence of MAVD in TAVR patients, investigate its association with paravalvular regurgitation (PVR), and analyse its impact on long-term mortality after TAVR. We conducted a registry-based cohort study using the Vienna TAVR registry, enrolling patients who underwent TAVR at Medical University of Vienna between January 2007 and May 2020 with available transthoracic echocardiography before and after TAVR (n = 880). Data analysis included PVR incidence and long-term survival outcomes. A total of 647 (73.52%) out of 880 patients had ≥ mild aortic regurgitation next to severe AS. MAVD was associated with PVR compared with isolated AS with an odds ratio of 2.06, 95% confidence interval (CI): 1.51-2.81 (P = <0.001). More than mild PVR after TAVR (n = 168 out of 880: 19.09%) was related to higher mortality compared with the absence of PVR with a hazard ratio (HR) of 1.33, 95% CI: 1.05- 1.67 (P = 0.016). MAVD patients developing ≥ mild PVR after TAVR were also associated with higher mortality compared with the absence of PVR with an HR of 1.30 and 95% CI: 1.04-1.62 (P = 0.022). MAVD is prevalent among TAVR patients and presents unique challenges, with increased PVR risk and worse outcomes compared with isolated AS. Long-term survival for MAVD patients, not limited to those developing PVR post-TAVR, is compromised. Earlier intervention before the occurrence of structural myocardial damage or surgical valve replacement might be a potential workaround to improve outcomes.

Assess the Outcomes of Transcatheter Aortic Valve Replacement in Bicuspid Valve with Mixed Disease versus Predominant Aortic Stenosis.

In mixed aortic valve disease (MAVD), the results of transcatheter aortic valve replacement (TAVR) are conflicting. There is limited data on the outcomes of TAVR in patients with bicuspid aortic valve (BAV) and MAVD. The objective of this study is to compare outcomes after TAVR in BAV patients with MAVD and predominant aortic stenosis (PAS). Patients with BAV who underwent TAVR between January 2016 and April 2023 were included. The primary outcome was device success. The secondary endpoints were periprocedural mortality and other complications as defined by the Valve Academic Research Consortium-3 (VARC-3). Propensity score matching was used to minimize potential confounding. A total of 262 patients were included in this study, 83 of whom had MAVD. The median age was 72 years, and 55.7% were male. The baseline comorbidity risk files were comparable between the two groups. Patients with MAVD had more mitral regurgitation, tricuspid regurgitation and pulmonary hypertension, larger annular and left ventricular outflow tract dimensions, and more severe calcification than PAS. In the unmatched population, MAVD patients had similar device success rate (69.9% vs 79.9%, P=0.075) and 30-day mortality (3.6% vs 3.4%, P=1) compared to PAS. Propensity score matching resulted in 66 patient pairs. Device success rate were still comparable in the matched population. Other clinical outcomes, including stroke, bleeding (type 2-4), major vascular complications, acute kidney injury (stage 2-4) and permanent pacemaker implantation, were comparable between the two groups. Multivariable logistic regression analysis did not show MAVD to be an independent negative predictor of device success. At one year, survival was similar between patients with MAVD and those with PAS. For the bicuspid valve, patients with MAVD had a more challenging anatomy. MAVD patients associated with comparable 30-day clinical outcomes after TAVR compared to PAS patients in patients with BAV.

Predictors of outcome in patients with moderate mixed aortic valve disease

ObjectivesGrading the severity of moderate mixed aortic stenosis and regurgitation (MAVD) is challenging and the disease poorly understood. Identifying markers of haemodynamic severity will improve risk stratification and potentially guide...

Outcomes of aortic valve repair in children stratified by complexity: Which outcome for which lesion?

ObjectiveAortic valvuloplasty frequency has significantly increased over the past 15 years. Surgical repair varies in complexity depending on valvular lesions. Our aim is to report results on the whole spectrum of aortic valvuloplasty techniques. MethodsAll children who consecutively underwent aortic valvuloplasty for aortic stenosis and/or aortic insufficiency between January 2006 and December 2020 at Necker Sick Children's Hospital (Paris, France) were included in a retrospective cohort study. Aortic valvuloplasty techniques were classified into 3 difficulty levels: (1) simple repair, corresponding to commissurotomy and/or shaving in aortic stenosis (AS) in neonates (group 1) and children >1 month (group 2); (2) intermediate-complexity repair, corresponding to commissuroplasty, leaflet resuspension, and fenestration closure in aortic insufficiency (leaflet prolapse in connective tissue disease, isolated leaflet prolapse and Laubry–Pezzi groups); and (3) complex repair requiring a pericardial patch to restore a functional aortic valve in mixed aortic valve disease (bicuspidization with neocommissure and cusp extension groups). ResultsDuring the study period, 324 children underwent aortic valvuloplasty. Survival and freedom from aortic valve reintervention at 10 years were, respectively, 86.1% and 50.9% in neonates with AS, 95.2% and 71.7% in children >1 month with AS, 93.8% and 79.5% in leaflet prolapse in connective tissue disease, 97.7% and 91.9% in isolated leaflet prolapse, 100% and 88% in those with Laubry–Pezzi syndrome, 97.4% and 84.8% in bicuspidization with neocommissure, and 100% and 54.2% in the cusp extension. ConclusionsDurability of aortic valvuloplasty techniques is satisfactory and offers the possibility to delay the Ross procedure, regardless of the lesion's complexity.

Moderate mixed aortic valve disease -evaluation, treatment and prognosis of patients referred to heart valve center

Abstract Background Indications for valve intervention in mixed aortic valve disease (MAVD) are not clearly defined. Decision is usually based on predominant lesion, extrapolated from guidelines for isolated aortic stenosis (AS) or aortic regurgitation (AR). However, data have been published suggesting that the prognosis of patients who have both moderate AS and moderate AR is not benign and may be similar to the prognosis of isolated severe AS. Goal: To assess diagnostic process, decision making and prognosis in patients with MAVD and moderate stenosis and regurgitation examined in a tertiary referral centre. Methods Patients with MAVD and EF ≥50% examined at tertiary referral center in years 2010-2021 were retrospectively identified. MAVD was defined as moderate AS by aortic valve area &amp;gt;1,0 cm2 and ≤1,5 cm2 and moderate AR by integrative assessment. Patients with more than mild to moderate disease of other valves were excluded. Results A total of 85 patients were eligible, mean age 66,4±7,9 years, males/females 58/27, 40 (47.1%) with bicuspid or monocuspid aortic valve, 50 asymptomatic. During a mean follow-up (F-U) of 5.9±3.6 years, 20 patients died and 46 underwent aortic valve replacement (AVR). At 1, 2, and 5 years of F-U, the mortality rate was 3.5%, 7.1% and 15.3% and the rate of AVR reached 23.5%, 30.6% and 43.5%, respectively. At 1, 2 and 5 years 61 (71.7%), 54 (63.5.%) and 40 (47.1%) patients were alive and free of AVR. In 10/13 patients who died within 5 years, MAVD was classified as nonsevere. Therefore, these patients were treated conservatively and eight of them died without AVR. Except one, all had peak velocity at aortic orifice &amp;lt;4 m/s. In all 6 patients who died within 2 years, MAVD was classified as nonsevere on index examination, AVR was indicated and performed only in 1 due to associated aortic aneurysm. Conclusions MAVD where both AS and AR are moderate is not a benign condition. Its overall severity is often underestimated, indication criteria for AVR are not clear and substantial proportion of patients die while being treated conservatively. These patients should be followed closely and lower threshold for aortic valve replacement/repair may be appropriate.

Survival and predictors of outcome in moderate mixed aortic valve disease

Abstract Background Coexisting moderate aortic stenosis and regurgitation (MAVD) is common. The haemodynamic effect of MAVD is poorly understood with sparse data to guide risk stratification. Purpose This study aims to compare all-cause mortality in moderate MAVD with matched controls and identify markers associated with prognosis. Methods Patients with both moderate aortic stenosis (aortic valve area [AVA] 1.0-1.5cm2) and regurgitation (vena contracta [VC] 0.3-0.6cm) were identified from a multicentre registry. All-cause mortality was compared to an age and sex matched UK population. The association between echocardiographic and clinical metrics with all-cause mortality was evaluated. Results 207 patients were included, age 78 [66-84] years and moderate MAVD (AVA 1.2 [1.1- 1.4]cm2 and VC 0.4 [0.4-0.5]cm). Over a median follow up of 3.2 years, 75/207 (36.2%) patients died. Patients with moderate MAVD had a significantly higher mortality compared to age and sex matched controls (36% versus 14.3%), p&amp;lt;0.001. Peak aortic jet velocity (Vmax) was the only haemodynamic metric independently associated with mortality [hazard ratio (HR): 0.61, 95% confidence interval (CI): 0.39-0.93; p=0.02] in a multivariate model along with age, creatinine and previous cerebrovascular accident. Compared to patients with Vmax &amp;gt;3m/sec, those with Vmax ≤3.0m/s had lower LVEF and stroke volume and a higher mortality (HR: 1.76, 95% CI: 1.10-2.80; p=0.017). Conclusions Moderate MAVD is associated with reduced survival compared to age and sex matched controls. Patients with discordant low Vmax ≤3 m/sec, have disproportionately worse outcome and may represent a high risk ‘low flow’ phenotype.Figure 1

Left ventricular reverse remodeling after transcatheter aortic valve replacement for predominant aortic stenosis and mixed aortic valve disease.

Mixed aortic valve disease (MAVD) is a frequent concomitant valve disease with unique cardiac pathological changes compared to predominant aortic stenosis (PAS). The previous studies about the MAVD are contradictory. Therefore, a new perspective is needed to assess the value of TAVR for this cohort of patients. From January 2018 to December 2021, 90 MAVD patients and 72 PAS patients who underwent TAVR in our hospital were collected. 1:1 propensity score matching analysis was used to control the bias in patient selection. The dynamic changes in left ventricular morphology and hemodynamics were compared by generalized estimating equations. Univariate or multivariate logistic regression analysis was used to screen for independent risk factors for the non-occurrence of left ventricular reverse remodeling (non-LVRR). After the matching procedure, 112 patients were included in the analysis (56 in each group). Baseline characteristics were similar between the two groups. LVRR occurred in both groups, but MAVD had greater left ventricular end-diastolic volume index and left ventricular mass index, a higher incidence of mitral regurgitation (MR), and a more pronounced transformation of ventricular geometry patterns. Post-operative MR (odd ratio [OR]: 10.05; 95% confidence interval [CI]: 2.08-48.57; p < .001) and coronary artery disease (OR: 2.82; 95% CI: 1.08-7.34; p = .034) were independent risk factors for non-LVRR. LVRR also occurs in patients with MAVD, post-operative MR and coronary artery disease were independent risk factors for non-LVRR.

Clinical impact of aortic valve replacement in patients with moderate mixed aortic valve disease.

Information is scarce regarding the clinical implications of aortic valve replacement (AVR) for patients suffering from moderate mixed aortic valve disease (MAVD), characterized by a combination of moderate aortic stenosis (AS) and regurgitation (AR). The objective of this retrospective study was to explore the clinical effects of AVR in individuals with moderate MAVD. We examined the clinical data from patients with moderate MAVD and preserved left ventricular ejection fraction, who had undergone echocardiography in the period spanning from 2010 to 2018. Moderate AS was defined as aortic valve area index of 0.60-0.85 cm2/m2 and peak velocity of 3.0-4.0 m/s. Moderate AR was defined as a vena contracta width of 3.0-6.0 mm. The primary endpoint was a composite of all-cause death and heart failure hospitalization. Among 88 patients (mean age, 74.4 ± 6.8 years; 48.9%, men), 44 (50.0%) required AVR during a median follow-up period of 3.3 years (interquartile range, 0.5-4.9). Mean values of specific aortic valve variables are as follows: aortic valve area index, 0.64 ± 0.04 cm2/m2; peak velocity, 3.40 ± 0.30 m/s; and vena contracta width, 4.1 ± 0.7 mm. The primary endpoint occurred in 32 (36.4%) patients during a median follow-up duration of 5.3 years (interquartile range, 3.2-8.0). Multivariable analysis revealed that AVR was significantly associated with the endpoint (hazard ratio, 0.248; 95% confidence interval, 0.107-0.579; p = 0.001) after adjusting for age, B-type natriuretic peptide, and the Charlson comorbidity index. Patients who underwent AVR during follow-up had significantly lower incidence rates of the endpoint than those managed with medical treatment (10.2% vs. 44.1% at 5 years; p < 0.001). Approximately half of the patients diagnosed with moderate MAVD eventually necessitated AVR throughout the period of observation, leading to positive clinical results. Vigilant tracking of these patients and watchful monitoring for signs requiring AVR during this time frame are essential.

Transcatheter Aortic Valve Implantation in Mixed Aortic Valve Disease: A Multicenter Study

Mixed aortic valve disease (MAVD), defined by the concurrent presence of aortic stenosis (AS) and insufficiency is frequently seen in patients who have undergone transcatheter aortic valve implantation (TAVI). However, studies comparing the outcomes of TAVI in MAVD versus isolated AS have demonstrated conflicting results. Therefore, we aim to assess the outcomes of TAVI in patients with MAVD in comparison with those with isolated severe AS. Patients who underwent native valve TAVI for severe AS at 3 tertiary care academic centers between January 2012 and December 2020 were included and categorized into 3 groups based on concomitant aortic insufficiency (AI) as follows: group 1, no AI; group 2, mild AI; and group 3, moderate to severe AI. Outcomes of interest included all-cause mortality and all-cause readmission rates at 30days and 1year. Other outcomes include bleeding, stroke, vascular complications, and the incidence of paravalvular leak at 30days after the procedure. Of the 1,588 patients who underwent TAVI during the study period, 775 patients (49%) had isolated AS, 606 (38%) had mild AI, and 207 (13%) had moderate to severe AI. Society of Thoracic Surgeons risk scores were significantly different among the 3 groups (5% in group 1, 5.5% in group 2, and 6% in group 3, p=0.003). Balloon-expandable valves were used in about 2/3 of the population. No statistically significant differences in 30-day or 1-year all-cause mortality and all-cause readmission rates were noted among the 3 groups. Post-TAVI paravalvular leak at follow-up was significantly lower in group 1 (2.3%) and group 2 (2%) compared with group 3 (5.6%) (p=0.01). In summary, TAVI in MAVD is associated with comparable outcomes at 1 year compared with patients with isolated severe AS.

Prognostic utility of N-terminal pro B-type natriuretic peptide ratio in mixed aortic valve disease

ObjectiveWe aimed to assess the incremental prognostic value of N-terminal-pro-B-type natriuretic peptide (Nt-proBNP) for risk stratification in mixed aortic valve disease (MAVD) patients.MethodsWe included 556 (73±12 years, 37% women) consecutive...

Prevalence, characteristics and prognostic impact of aortic valve disease in patients with heart failure and reduced, mildly reduced, and preserved ejection fraction: An analysis of the ESC Heart Failure Long-Term Registry.

To assess the prevalence, clinical characteristics, and outcomes of patients with heart failure (HF) with or without moderate to severe aortic valve disease (AVD) (aortic stenosis [AS], aortic regurgitation [AR], mixed AVD [MAVD]). Data from the prospective ESC HFA EORP HF Long-Term Registry including both chronic and acute HF were analysed. Of 15 216 patients with HF (62.5% with reduced ejection fraction, HFrEF; 14.0% with mildly reduced ejection fraction, HFmrEF; 23.5% with preserved ejection fraction, HFpEF), 706 patients (4.6%) had AR, 648 (4.3%) AS and 234 (1.5%) MAVD. The prevalence of AS, AR and MAVD was 6%, 8%, and 3% in HFpEF, 6%, 3%, and 2% in HFmrEF and 4%, 3%, and 1% in HFrEF. The strongest associations were observed for age and HFpEF with AS, and for left ventricular end-diastolic diameter with AR. AS (adjusted hazard ratio [HR] 1.43, 95% confidence interval [CI] 1.23-1.67), and MAVD (adjusted HR 1.37, 95% CI 1.07-1.74) but not AR (adjusted HR 1.13, 95% CI 0.96-1.33) were independently associated with the 12-month composite outcome of cardiovascular death and HF hospitalization. The associations between AS and the composite outcome were observed regardless of ejection fraction category. In the ESC HFA EORP HF Long-Term Registry, one in 10 patients with HF had AVD, with AS and MAVD being especially common in HFpEF and AR being similarly distributed across all ejection fraction categories. AS and MAVD, but not AR, were independently associated with increased risk of in-hospital mortality and 12-month composite outcome, regardless of ejection fraction category.

We Didn’t See That Coming: Right Eye Blindness Post-Cardiac Surgery

Postoperative visual loss (POVL) is a very rare but devastating event that can occur post-cardiac surgery. The most common cause of POVL is vascular occlusion. We present a case of a 39-year-old male with severe mixed aortic valve disease, who had to undergo double valve replacement (mechanical) due to extensive calcification. On postoperative day 7, he complained of sudden painless loss of vision in the right eye. He was diagnosed with right eye central retinal artery occlusion and was discharged home with permanent right eye blindness. Neuro-ophthalmologic complications following non-ocular surgery occur rarely. POVL occurs more likely when there are calcified heart valvular lesions, higher perioperative blood loss, hypotension, low systolic blood pressure, anaemia, hypothermia, prolonged surgery time and age &gt;50 years old. In our case report we have encountered a couple of risk factors for ischaemia which are heavily calcified aortic and mitral valves, lower mean arterial pressure and bypass time &gt;5 hours. Postoperative blindness can be avery serious and devastating problem with no known or established treatment. Stroke is a well-known and established complication of cardiac surgery, but central retinal artery occlusion causing loss of vision is rarely covered and explained.

Prognostic impact of left ventricular systolic dysfunction in patients with mixed aortic valve disease undergoing aortic valve replacement.

The implications of left ventricular remodeling and dysfunction before and after aortic valve replacement (AVR) for mixed aortic valve disease (MAVD) are not well understood. This study aims to evaluate the impact of AVR on left ventricular (LV) systolic function in MAVD, and determine the prognostic value of postoperative LV global longitudinal strain (LV-GLS) and LV ejection fraction (LVEF). We retrospectively assessed 489 consecutive patients with MAVD (defined as at least moderate aortic stenosis and at least moderate aortic regurgitation) and baseline LVEF ≥50%, who underwent AVR between February 2003 and August 2018. All patients had baseline echocardiography, whereas 192 patients underwent postoperative echocardiography between 3 and 18 months after AVR. The primary endpoint was all-cause mortality. Mean age was 65±15 years, and 65% were male. AVR in MAVD patients has a neutral effect on LV systolic function quantitated by LVEF and LV-GLS. During a median follow-up period of 5.8 years, 65 patients (34%) of 192 patients with follow-up echocardiography died. The patients with postoperative LVEF ≥50% had better survival than those with postoperative LVEF<50% (P<.001). Furthermore, among patients with postoperative LVEF ≥50%, mortality differed between patients with postoperative LV-GLS worse than -15% and those with postoperative LV-GLS better than -15% (P<.001). In patients with MAVD who underwent AVR, the mean postoperative LV-GLS and LVEF remain at a similar value to baseline. However, worse postoperative LV-GLS and LVEF were both independently associated with higher mortality in this population.

Comparative Outcomes of TAVR in Mixed Aortic Valve Disease and Aortic Stenosis: A Meta-analysis.

Transcatheter aortic valve replacement (TAVR) has become a suitable alternative to surgical aortic valve replacement (SAVR) for the treatment of symptomatic severe aortic stenosis (AS). A high proportion of patients with AS have mixed aortic valve disease (MAVD) with mild or more concurrent aortic regurgitation (AR). Differential outcomes of TAVR among patients with AS and MAVD have not been well characterized.We compared 1-year mortalities following TAVR among patients with MAVD and AS. We conducted a meta-analysis of studies published in PubMed/Medline. The primary outcome was 1-year all-cause mortality following TAVR among patients with MAVD vs. AS. Secondary endpoints were: (1) incidence of AR within 30days following TAVR (post TAVR AR); and (2) 1-year all-cause mortality within each group stratified according to severity of post TAVR AR. Nine studies involving 9505 participants were included in the analysis. At 1year following TAVR, mortality was lower in MAVD than in AS; HR 0.89, 95% CI 0.81-0.98. The mortality advantage increased when pre-TAVR AR was moderate or more; HR 0.84, 95% CI 0.72-0.99. The mortality advantage was attenuated after correction for publication bias. There was a higher risk of post TAVR AR in the MAVD group; OR 1.51, 95% CI 1.20-1.90 but the impact on mortality of moderate vs. mild post TAVR AR was greater among patients with AS than in patients with MAVD HR 1.67 95% CI 0.89-3.14 vs. 0.93 95% CI 0.47-1.85. Patients with MAVD have similar or improved survival 1year after TAVR compared to those with AS.

Abstract 11499: Management of Mixed Aortic Valve Disease Patients: Can N-terminal Pro-Brain Natriuretic Peptide Ratio Improve Risk Assessment?

Introduction: Risk assessment of mixed aortic valve disease (MAVD: concomitant aortic stenosis [AS] and regurgitation [AR]) patients is challenging, especially in non-severe lesions. In fact, these patients often present LV dysfunction after aortic valve replacement (AVR), and concomitant non-severe lesions appear to have similar outcomes than severe AS. Objective: We aimed to evaluate the prognostic value of N-terminal pro-brain natriuretic peptide (NT-proBNP) ratio in risk stratification of MAVD patients. Methods: A total of 582 consecutive MAVD patients (mean age 73±11 years, 63% men) with at least concomitant mild AS and AR in whom a measurement of NT-proBNP during the same episode of care was available were included. NT-proBNP ratio (i.e., plasma level divided by maximal normal values for age and sex derived from Mayo Clinic laboratory) was calculated. In subgroups analyses, patients were divided according to MAVD pattern (severe AS or AR [n=364] and non-severe AS/AR [n=218]) and according to treatment strategy (early AVR [i.e., ≤3 months, n=429] or initial medical treatment [MT; n=153]). Results: Baseline median NT-proBNP ratio was 3.5 (IQR: 1.2-10.0). A total of 105 patients died during a median follow-up of 5.6 (2.8-6.1) years. Overall, NT-proBNP ratio ≥3 was significantly associated with long-term all-cause mortality in multivariable analyses adjusted for clinical and echocardiographic parameters as well as AVR as a time-dependent variable . NT-proBNP-ratio also showed incremental prognostic value at 1, 2 and 5 years over EuroSCORE II and echocardiographic parameters (all, net reclassification index &gt;0.45; p≤0.005). In all subgroups, NT-proBNP-ratio ≥3 remained independently associated with excess mortality ( severe AS or AR - HR[95CI]: 3.30[1.54-7.05], non-severe AS/AR : 2.14[1.03-4.43], early AVR : 2.48[1.16-5.39], initial MT : 2.72[1.02-7.22]; all p≤0.04). In patients who underwent early AVR, NT-proBNP-ratio ≥3 was also associated with higher 30-days mortality (9[4%] vs. 1[0.5%], p=0.02). Conclusions: In this series of MAVD patients, NT-proBNP-ratio was a powerful predictor of mortality, even in non-severe lesions, early AVR and medically treated patients. AVR may be reasonable before reaching an NT-proBNP-ratio ≥3.

ADDITIVE VALUE OF NT-PROBNP RATIO IN THE MANAGEMENT OF MIXED AORTIC VALVE DISEASE PATIENTS

ADDITIVE VALUE OF NT-PROBNP RATIO IN THE MANAGEMENT OF MIXED AORTIC VALVE DISEASE PATIENTS

Impact of Left Ventricular Ejection Fraction on Clinical Outcomes in Bicuspid Aortic Valve Disease

BackgroundThe prognostic impact of left ventricular ejection fraction (LVEF) in patients with bicuspid aortic valve (BAV) disease has not been previously studied. ObjectivesThe purpose of this study was to determine the prognostic impact of LVEF in BAV patients according to the type of aortic valve dysfunction. MethodsWe retrospectively analyzed the data collected in 2,672 patients included in an international registry of patients with BAV. Patients were classified according to the type of aortic valve dysfunction: isolated aortic stenosis (AS) (n = 749), isolated aortic regurgitation (AR) (n = 554), mixed aortic valve disease (MAVD) (n = 190), or no significant aortic valve dysfunction (n = 1,179; excluded from this analysis). The study population was divided according to LVEF strata to investigate its impact on clinical outcomes. ResultsThe risk of all-cause mortality and the composite endpoint of aortic valve replacement or repair (AVR) and all-cause mortality increased when LVEF was <60% in the whole cohort as well as in the AS and AR groups, and when LVEF was <55% in MAVD group. In multivariable analysis, LVEF strata were significantly associated with increased rate of mortality (LVEF 50%-59%: HR: 1.83 [95% CI: 1.09-3.07]; P = 0.022; LVEF 30%-49%: HR: 1.97 [95% CI: 1.13-3.41]; P = 0.016; LVEF <30%: HR: 4.20 [95% CI: 2.01-8.75]; P < 0.001; vs LVEF 60%-70%, reference group). ConclusionsIn BAV patients, the risk of adverse clinical outcomes increases significantly when the LVEF is <60%. These findings suggest that LVEF cutoff values proposed in the guidelines to indicate intervention should be raised from 50% to 60% in AS or AR and 55% in MAVD.