Time Of Aortic Valve Replacement Research Articles

Transaortic septal myectomy at the time of aortic valve replacement for severe aortic stenosis: a case series of 55 cases

Abstract Introduction Symptomatic aortic valve stenosis (AS) is associated with asymmetric basal septal hypertrophy (ABSH) in 10% of cases. In this cohort, it has been suggested that rectification of the left ventricular outflow tract obstruction (LVOTO) by concomitant septal myectomy (CSM) can improve the results of aortic valve replacement (AVR). Objective This study aims to present the technique of AVR with CSM for severe AS with ABSH and to determine the associated early and late post-operative outcomes. Methods Fifty-five patients were prospectively recruited to undergo AVR with CSM between 2011 and 2021 at two centres. The primary outcomes were mortality within 30 days, incidence of post-operative ventricular septal defects (VSD) and prosthetic valve sizing. The secondary outcomes were in-hospital complications, permanent pacemaker implantation (PPI), survival at 15 months and changes on transthoracic echocardiogram. Results Post-operative mortality was 1.8% and this figure was unchanged at 15-month follow-up. No patients developed a post-operative VSD. Intra-operatively, it was found that in 94.6% cases the direct valve sizing increased by one, when compared to the measurement made before CSM. The indexed effective orifice area (iEOA) was > 85 cm2/m2 in 96.4% and no patients had an iEOA ≤ 0.75 cm2/m2. Four patients (7.3%) required PPI due to complete atrioventricular block. Conclusion AVR with CSM is a simple technique that can be utilised in severe AS with ABSH. There does not appear to be an increase in mortality or incidence of iatrogenic VSDs. Importantly, CSM allows for the implantation of a larger aortic valve compared to measurements made before CSM.

Novel Biomarkers and Advanced Cardiac Imaging in Aortic Stenosis: Old and New.

Currently, the symptomatic status and left ventricular ejection fraction (LVEF) play a crucial role in aortic stenosis (AS) assessment. However, the symptoms are often subjective, and LVEF is not a sensitive marker of left ventricle (LV) decompensation. Over the past years, the cardiac structure and function research on AS has increased due to advanced imaging modalities and potential therapies. New imaging parameters emerged as predictors of disease progression in AS. LV global longitudinal strain has proved useful for risk stratification in asymptomatic severe AS patients with preserved LVEF. The assessment of myocardial fibrosis by cardiac magnetic resonance is the most studied application and offers prognostic information on AS. Moreover, the usage of biomarkers in AS as objective measures of LV decompensation has recently gained more interest. The present review focuses on the transition from compensatory LV hypertrophy (H) to LV dysfunction and the biomarkers associated with myocardial wall stress, fibrosis, and myocyte death. Moreover, we discuss the potential impact of non-invasive imaging parameters for optimizing the timing of aortic valve replacement and provide insight into novel biomarkers for possible prognostic use in AS. However, data from randomized clinical trials are necessary to define their utility in daily practice.

Is myocardial fibrosis appropriately assessed by 2D strain derived integrated backscatter?

Abstract Introduction Calibrated integrated backscatter (cIB) may be obtained from bidimensional (2D) strain echocardiography as a quantification measurement of myocardial ultrasound reflectivity. Increased collagen content of the myocardium modifies tissue reflectivity and cIB is suggested as a marker of left ventricular (LV) fibrosis. However, its diagnostic accuracy is not fully established. Aim To assess the correlation between cIB by 2D strain and LV myocardial fibrosis (MF), as evaluated by non-invasive imaging and histopathology. Methods Correlation study from a cohort of 157 patients with severe symptomatic aortic stenosis (AS) referred for surgical aortic valve replacement (AVR). Patients with complete preoperative transthoracic echocardiography, cardiac magnetic resonance (CMR) and endomyocardial biopsy (EMB) obtained from the anterior basal septum at the time of AVR were selected. Two groups of 30 patients were evaluated, with and without late gadolinium enhancement (LGE) at CMR. Integrated Backscatter was obtained at QRS peak in decibels (dB) from both parasternal long axis (PLAX) and apical-three-chamber (A3C) cine clips at Qanalysis. cIB was calculated by subtracting the pericardial intensity from the average of the anteroseptal and basal inferolateral wall values. Correlation analysis was performed for the whole group of patients with global and segmental (anterior basal septum) values of native T1 and extracellular volume (ECV), and EMB collagen volume fraction (CVF) from Masson´s Trichrome staining. IBS values were compared in both group of patients. Results 60 patients (74 [36-74] years, 45% male) with high gradient (mean gradient: 63±20mmHg), normal flow (45±10mL/m2), preserved ejection fraction (60±9%) AS were included. Basal septal cIB was –9.17±9.45dB and –17.45 (–31.2–10.95) dB from A3C and PLAX views, respectively. These indexes did not correlate with basal septum thickness or global LV mass. Absolute and cIB did not correlate neither with global and regional T1 and ECV values, nor with CVF at EMB. These were not significantly different in both groups of patients and there was no correlation between cIB values and mass of replacement MF in patients with LGE. Conclusion In these cohort of patients with classical severe AS, there was no correlation of cIB with imaging markers of both replacement and diffuse MF. cIB also didn´t correlate with CVF at histopathology. These findings suggest that reflectivity indexes are not suitable for myocardial tissue characterization in this setting.

The Mortality Burden of Untreated Aortic Stenosis

BackgroundThe American College of Cardiology/American Heart Association guidelines recommend the assessment and grading of severity of aortic stenosis (AS) as mild, moderate, or severe, per echocardiogram, and recommend aortic valve replacement (AVR) when the AS is severe. ObjectivesThe authors sought to describe mortality rates across the entire spectrum of untreated AS from a contemporary, large, real-world database. MethodsWe analyzed a deidentified real-world data set including 1,669,536 echocardiographic reports (1,085,850 patients) from 24 U.S. hospitals (egnite Database, egnite). Patients >18 years of age were classified by diagnosed AS severity. Untreated mortality and treatment rates were examined with Kaplan-Meier (KM) estimates, with results compared using the log-rank test. Multivariate hazards analysis was performed to assess associations with all-cause mortality. ResultsAmong 595,120 patients with available AS severity assessment, the KM-estimated 4-year unadjusted, untreated, all-cause mortality associated with AS diagnosis of none, mild, mild-to-moderate, moderate, moderate-to-severe, or severe was 13.5% (95% CI: 13.3%-13.7%), 25.0% (95% CI: 23.8%-26.1%), 29.7% (95% CI: 26.8%-32.5%), 33.5% (95% CI: 31.0%-35.8%), 45.7% (95% CI: 37.4%-52.8%), and 44.9% (95% CI: 39.9%-49.6%), respectively. Results were similar when adjusted for informative censoring caused by treatment. KM-estimated 4-year observed treatment rates were 0.2% (95% CI: 0.2%-0.2%), 1.0% (95% CI: 0.7%-1.3%), 4.2% (95% CI: 2.0%-6.3%), 11.4% (95% CI: 9.5%-13.3%), 36.7% (95% CI: 31.8%-41.2%), and 60.7% (95% CI: 58.0%-63.3%), respectively. After adjustment, all degrees of AS severity were associated with increased mortality. ConclusionsPatients with AS have high mortality risk across all levels of untreated AS severity. Aortic valve replacement rates remain low for patients with severe AS, suggesting that more research is needed to understand barriers to diagnosis and appropriate approach and timing for aortic valve replacement.

Incremental Value of Global Longitudinal Strain for Confirming Heart Failure–Related Symptoms in Severe Aortic Stenosis

The indications or timing of aortic valve replacement for symptomatic aortic stenosis (AS) are based on a patient's life expectancy and symptoms. However, clinical decision-making may be difficult because symptoms are subjective and cannot be quantitatively assessed and confirmed. This study aimed to evaluate the association between heart failure (HF)-related symptoms and cardiac hemodynamic left ventricular deformations in patients with severe AS using transthoracic echocardiographic assessments of left ventricular global longitudinal strain (LV-GLS). The medical records of patients hospitalized for AS between February 2017 and September 2019 were retrospectively screened. Independent cardiologists analyzed the transthoracic echocardiographic images of a digital echocardiography database. The cohort comprised 177 hospitalized patients with severe AS and no history of HF. The subgroup with HF-related symptoms included 87 patients, whereas that without HF-related symptoms included 90 patients. In 145 patients without atrial fibrillation, the left atrial volume index (LAVI) and LV-GLS were significantly associated with HF-related symptoms (odds ratio 1.033, 95% confidence interval 1.008 to 1.059, p = 0.011 and odds ratio 1.224, 95% confidence interval 1.118 to 1.340, p <0.0001, respectively). Moreover, the combination of brain natriuretic peptide level, LAVI, and LV-GLS showed better diagnostic accuracy than the combination of brain natriuretic peptide level and LAVI (p = 0.005). However, there were no such tendencies in 32 patients with atrial fibrillation. The HF-related symptoms in patients with severe AS were strongly linked to LV-GLS. LV-GLS showed incremental value for confirming HF-related symptoms.

Echocardiographic and Clinical Outcomes in Symptomatic Patients With Less Than Severe Aortic Stenosis After Supra-Annular Self-Expanding Transcatheter Aortic Valve Replacement

Optimal timing for aortic valve replacement in symptomatic patients with less than severe aortic stenosis (AS) is not well defined. There is limited information on the benefit of valve replacement in these patients. Symptomatic patients with less than severe AS, defined as a mean aortic gradient ≥20 and <40mm Hg, peak aortic velocity >3 and <4m/s, and aortic valve area >1.0 and <1.5cm2, enrolled in the Society for Thoracic Surgery/American College of Cardiology Transcatheter Valve Therapy Registry and who underwent attempted supra-annular, self-expanding transcatheter aortic valve replacement (TAVR) were reviewed. Site-reported valve hemodynamics, clinical events, and quality of life metrics were analyzed at 30days and 1year after the procedure. A total of 1,067 patients with attempted TAVR (mean age 78.4 ± 8.4years; Society for Thoracic Surgery score 4.7 ± 3.4%) were found to have symptoms but less than severe AS. From baseline to postprocedure, mean gradient decreased (29.9 ± 4.9 vs 8.4 ± 4.8mm Hg, p <0.001), and aortic valve area increased (1.2 ± 0.1 vs 2.2 ± 0.7cm2, p <0.001). Clinical events included 30-day and 1-year all-cause mortality (1.5% and 9.6%), stroke (2.2% and 3.3%), and new pacemaker implantation (18.1% and 20.9%). There were statistically significant improvements in the New York Heart Association functional class and Kansas City Cardiomyopathy Questionnaire at 30days and 1year. In conclusion, patients with symptomatic but less than severe AS who underwent supra-annular, self-expanding TAVR experienced improved valve hemodynamics and quality of life measures 1year after the procedure. Randomized studies of TAVR versus a control arm in symptomatic patients with less than severe AS are ongoing.

Electrocardiographic Markers of Adverse Left Ventricular Remodeling and Myocardial Fibrosis in Severe Aortic Stenosis.

The optimal timing for aortic valve replacement (AVR) in aortic stenosis (AS) is still controversial and may be guided by markers of adverse left ventricular (LV) remodeling. We aim to assess electrocardiographic (ECG) strain in relation to LV remodeling and myocardial fibrosis. 83 severe AS patients underwent surgical AVR, with preoperative 12-lead ECG, cardiovascular magnetic resonance with T1 mapping and echocardiography with global longitudinal strain analysis. Collagen volume fraction (CVF) was measured in myocardial biopsies sampled during AVR. Patients with ECG strain had more severe AS, more advanced LV remodeling and evidence of heart failure. Patients with ECG strain had more diffuse fibrosis, as evident by higher mean native T1 values (974.8 ± 34 ms vs. 946.5 ± 28 ms, p < 0.001). ECG strain was the only predictor of increased LV mass index on multivariate regression analysis (OR = 7.10, 95% CI 1.46-34.48, p = 0.02). Patients with persistent ECG strain at 1 year following AVR had more advanced LV remodeling and more histological fibrosis (CVF 12.5% vs. 7.3%, p = 0.009) at baseline assessment. Therefore, ECG strain is a marker of adverse LV remodeling and interstitial myocardial fibrosis. Lack of improvement in ECG strain following AVR indicates more advanced baseline LV injury and higher levels of myocardial fibrosis.

Health Care Resource, Economic, and Readmission Implications After Acute Decompensated Aortic Stenosis–A Nationwide Study

Acute decompensated aortic stenosis (ADAS) is common. The cumulative burden of ADAS from a clinical, health care resource, and financial perspective is unknown. This study sought to assess the national impact of ADAS compared with electively treated, stable patients with aortic stenosis (non-ADAS). Using the National Readmissions Database between 2016 and 2019, patients with ADAS and non-ADAS were identified using International Classification of Diseases, Tenth Revision codes. Patients with ADAS were propensity-matched to non-ADAS patients (1:2) using age, gender, and Charlson co-morbidity index. We compared in-hospital mortality, length of stay (LOS), health care-associated costs, and 90-day readmission data between the 2 cohorts. A total of 51,498 propensity-matched patients were included in this study: median age 75years, 64% men. The in-hospital mortality for ADAS was higher than non-ADAS (2.8% vs 1.5%, p <0.0001). The LOS during the index admission was longer for ADAS (9 [5 to 13] vs 4 [2 to 6] days, p <0.0001). The health care-associated costs per patient was greater for ADAS ($55,450.0 [41,860.4 to 74,500.7] vs $43,405.7 [34,218.5 to 56,034.8], p <0.0001). Readmission to hospital within 90days was more frequent in ADAS (21.1 vs 16.8%, p <0.001). The in-hospital mortality during readmission was higher with ADAS (3.9% vs 2.8%, p=0.004). The readmission LOS was longer with ADAS (4 [2 to 7] vs 3 [2 to 6] days, p <0.0001). In conclusion, ADAS imposes a significant burden clinically and financially and on health care resources compared with non-ADAS during the index admission and 90-day follow-up. There is an urgent need to predict ADAS and optimize the timing of aortic valve replacement to reduce the incidence and the burden associated with ADAS.

Is myocardial fibrosis appropriately assessed by 2D strain derived integrated backscatter?

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Calibrated integrated backscatter (cIBS) may be obtained from bidimensional (2D) strain echocardiography as a quantification measurement of myocardial ultrasound reflectivity. Increased collagen content of the myocardium modifies tissue reflectivity and cIBS is suggested as a marker of left ventricular (LV) fibrosis. However, its diagnostic accuracy is not established. Aim To assess the correlation between cIBS by 2D strain and LV myocardial fibrosis (MF), as evaluated by non-invasive imaging and histopathology. Methods Correlation study from a cohort of 157 patients with severe symptomatic aortic stenosis (AS) referred for surgical aortic valve replacement (AVR). Patients with complete preoperative transthoracic echocardiography, cardiac magnetic resonance (CMR) and endomyocardial biopsy (EMB) obtained from the anterior basal septum at the time of AVR were selected. Two groups of 30 patients were evaluated, with and without late gadolinium enhancement (LGE) at CMR. IBS was obtained at QRS peak in decibels (dB) from both parasternal long axis (PLAX) and apical three chamber (A3C) cine clips at Qanalysis (Figure 1A). cIBS was calculated by subtracting the pericardial intensity from the average of the anteroseptal and basal inferolateral wall values. Correlation analysis was performed for the whole group of patients with global and segmental (anterior basal septum) values of native T1 and extracellular volume (ECV), and EMB collagen volume fraction (CVF) from Masson´s Trichrome staining. IBS values were compared in both group of patients. Results 60 patients (73 [68–74] years, 45% male) with high gradient (mean gradient: 64±20mmHg), normal flow (45±10mL/m2), preserved ejection fraction (60±9%) AS. Basal septal cIBS was −9.2±9.5dB and −16.3±7.9dB from A3C and PLAX views, respectively. These indexes did not correlate with basal septum thickness or global LV mass. Absolute and cIBS did not correlate neither with global and regional T1 and ECV values, nor with CVF at EMB (Figure 1B). These were not significantly different in both groups of patients and there was no correlation between cIBS values and mass of replacement MF in patients with LGE. Conclusion In these cohort of patients with classical severe AS, there was no correlation of cIBS with imaging markers of both replacement and diffuse MF. cIBS also didn´t correlate with CVF at histopathology. These findings suggest that reflectivity indexes are not suitable for myocardial tissue characterization in this setting.

Incidence, source, and prognostic impact of major bleeding across the spectrum of aortic stenosis

Severe aortic stenosis (AS) has been associated with bleeding. However, there is a lack of prospective assessment of bleeding events and their clinical significance in a large population of outpatients with variable degree of AS severity. To assess the incidence, source, determinants, and prognostic impact of major bleeding in patients with variable degree of AS severity. Between May 2016 and December 2017, consecutive outpatients were included. Major bleeding was defined as type ≥3 bleed using the Bleeding Academic Research Consortium definition. Cumulative incidence was calculated with death as the competing event. Data was censored at time of aortic valve replacement. Among 2,830 patients, 46 major bleeding events occurred (0.7%/year) during a median follow-up of 2.1 years (interquartile range: 1.4-2.7). Most frequent sites of bleeding were gastrointestinal (50%) and intracranial (30.4%). Major bleeding was significantly associated with all-cause mortality (hazard ratio: 5.93 (95% confidence interval 3.64-9.65); P < .001). AS severity was associated with major bleedings (P=.041). By multivariable analysis, severe AS was an independent determinant of major bleeding (hazard ratio vs mild AS: 3.59 [95% confidence interval 1.56-8.29]; P=.003). The increased risk of bleeding associated with severe AS was significantly exacerbated in patients using oral anticoagulation. In AS patients, major bleeding is rare but a strong independent predictor of death. AS severity is a determinant of bleeding events. Severe AS and oral anticoagulation should be identified as an association at very high risk of major bleeding.

Machine Learning Prediction Models of Optimal Time for Aortic Valve Replacement in Asymptomatic Patients

Currently, the decision of aortic valve replacement surgery time for asymptomatic patients with moderate-to-severe aortic stenosis (AS) is made by healthcare professionals based on the patient’s clinical biometric records. A delay in surgical aortic valve replacement (SAVR) can potentially affect patients’ quality of life. By using ML algorithms, this study aims to predict the optimal SAVR timing and determine the enhancement in moderate-to-severe AS patient survival following surgery. This study represents a novel approach that has the potential to improve decision-making and, ultimately, improve patient outcomes. We analyze data from 176 patients with moderate-to-severe aortic stenosis who had undergone or were indicated for SAVR. We divide the data into two groups: those who died within the first year after SAVR and those who survived for more than one year or were still alive at the last follow-up. We then use six different ML algorithms, Support Vector Machine (SVM), Classification and Regression Tree (C and R tree), Generalized Linear (GL), Chi-Square Automatic Interaction Detector (CHAID), Artificial Neural Network (ANN), and Linear Regression (LR), to generate predictions for the best timing for SAVR. The results showed that the SVM algorithm is the best model for predicting the optimal timing for SAVR and for predicting the post-surgery survival period. By optimizing the timing of SAVR surgery using the SVM algorithm, we observed a significant improvement in the survival period after SAVR. Our study demonstrates that ML algorithms generate reliable models for predicting the optimal timing of SAVR in asymptomatic patients with moderate-to-severe AS.

Temporal changes in aortic valve replacement according to age in Denmark: nationwide data from 2008 to 2020

Abstract Background Since the introduction of transcatheter aortic valve implantation (TAVI), the management of symptomatic severe aortic stenosis has changed. Recent published European guidelines (2021) favours TAVI over surgical aortic valve replacements (SAVR) in patients with older age (≥75 years of age) or patients with high surgical risk. The study of nationwide practice patterns for AVR is important and renders the possibility to evaluate whether clinical practice differs from current guidelines. Purpose To evaluate temporal changes in use of isolated aortic valve replacement (AVR) procedures according to age in the era of TAVI in Denmark. Methods We identified all first-time aortic valve replacement procedures (TAVI or SAVR) from 2008 until the end of 2020 through administrative registries in Denmark. Patients with no prior diagnosis of aortic stenosis at time of AVR were excluded. Patients with prior AVR or valve repair were excluded. SAVR was divided according to type of prostheses: surgical bioprostheses and mechanical prostheses. To evaluate changes according to age the study cohort was divided into two age groups: &amp;lt;75 and ≥75 years of age. Results Between 2008 and 2020, 12,313 first-time isolated AVR procedures were performed in Denmark. Volume of isolated AVR increased from 621 to 1256 procedures per year (ptrend &amp;lt;0.001). Isolated SAVR was performed in 6,548 patients (53.2%) and TAVI in 5,765 patients (46.8%). Median age of TAVI patients was 81.4 [76.9–85.2] years of age compared to 73.1 [68.0-≥77.7] in patients receiving surgical bioprostheses and TAVI patients had a higher degree of comorbidity (TAVI: 70% of patients with Charlson comorbidity score ≥1, surgical bioprostheses: 50% of patients with Charlson comorbidty score ≥1). TAVI increased during study period compared to isolated SAVR, where a decreasing trend was observed from 2014 and onwards. In &amp;lt;75-year-old patients, volume of TAVI significantly increased during study period (ptrend&amp;lt;0.001), whereas volume of surgical bioprostheses remained stable. Volume of mechanical prostheses decreased over time (ptrend &amp;lt;0.001) TAVI increased in ≥75-year-old patients (ptrend &amp;lt;0.001) and TAVI accounted for 91.5% of all isolated AVR procedures in 2020. In contrast, volume of isolated SAVR declined driven by a decreasing use of surgical bioprostheses (ptrend=0.001). (Figure 1). Conclusions Volume of isolated aortic valve replacement (AVR) doubled from 2008 and 2020. The increase in isolated AVR was driven by transcatheter aortic valve implantation (TAVI). TAVI has become the predominant choice of isolated AVR in management of aortic stenosis and our results suggest that real-world practise patterns are in line with current guideline recommendations. Funding Acknowledgement Type of funding sources: None.

DIFFERENCES IN RIGHT VENTRICULAR REMODELING AND ITS IMPACT ON SURVIVAL BETWEEN MEN AND WOMEN WITH AORTIC STENOSIS

Current guidelines recommends to treat tricuspid regurgitation/annulus dilation (TR/D) at the time of aortic valve replacement (AVR) for aortic stenosis (AS). However, sex-differences in TR/D and right ventricle (RV) remodeling in AS in patients with AS have not been investigated. We thus aimed to evaluated the sex-differences in TR/D, RV remodeling, as well as their importance on survival after AVR.

Association of Left Ventricular Remodeling Assessment by Cardiac Magnetic Resonance With Outcomes in Patients With Chronic Aortic Regurgitation

Chronic aortic regurgitation (AR) causes left ventricular (LV) volume overload, which results in progressive LV remodeling negatively affecting outcomes. Whether cardiac magnetic resonance (CMR) volumetric quantification can provide incremental risk stratification over standard clinical and echocardiographic evaluation in patients with chronic moderate or severe AR is unknown. To compare LV remodeling measurements by CMR and echocardiography between patients with and without heart failure symptoms and to verify the association of remodeling measurements of patients with chronic moderate or severe AR but no or minimal symptoms with clinical outcomes receiving medical management. This multicenter retrospective cohort study included consecutive patients with at least moderate chronic native AR evaluated by 2-dimensional transthoracic echocardiography and CMR examination within 90 days from each other between January 2012 and February 2020 at Allina Health System. Data were analyzed from June 2021 to January 2022. Clinical evaluation and risk stratification by CMR. The end point was a composite of death, heart failure hospitalization, or progression of New York Heart Association functional class while receiving medical management, censoring patients at the time of aortic valve replacement (when performed) or at the end of follow-up. Of the 178 included patients, 119 (66.9%) were male, 158 (88.8%) presented with no or minimal symptoms (New York Heart Association class I or II), and the median (IQR) age was 58 (44-69) years. Compared with patients with no or minimal symptoms, symptomatic patients had greater LV end-systolic volume index (LVESVi) by CMR (median [IQR], 66 [46-85] mL/m2 vs 42 [30-58] mL/m2; P < .001), while there were no significant differences by echocardiography (LVESVi: median [IQR], 38 [30-58] mL/m2 vs 27 [20-42] mL/m2; P = .07; LV end-systolic diameter index: median [IQR], 21 [17-25] mm/m2 vs 18 [15-22] mm/m2; P = .17). During the median (IQR) follow-up of 3.3 (1.6-5.8) years, 50 patients with no or minimal symptoms receiving medical management developed the composite end point, which, in multivariate analysis adjusted for age and EuroSCORE II, was independently associated with LVESVi of 45 mL/m2 or greater and aortic regurgitant fraction of 32% or greater, the latter adding incremental prognostic value to CMR volumetric assessment. In patients with chronic moderate or severe AR, patients presenting with heart failure symptoms have greater LVESVi by CMR than those with no or minimal symptoms. In patients with no or minimal symptoms, CMR quantification of LVESVi and AR severity may identify those at risk of death or incident heart failure and therefore should be considered in the clinical evaluation and decision-making of these patients.

Sex-Related Differences in Medically Treated Moderate Aortic Stenosis

BackgroundRecent data showed poor long-term survival in patients with moderate AS. Although sex differences in left ventricular (LV) remodeling and outcome are well described in severe AS, it has not been evaluated in moderate AS. MethodsIn this retrospective, multicenter study, patients with a first diagnosis of moderate AS diagnosed between 2001 and 2019 were identified. Clinical and echocardiographic parameters were recorded at baseline and compared between men and women. Patients were followed up for the primary endpoint of all-cause mortality with censoring at the time of aortic valve replacement. ResultsA total of 1895 patients with moderate AS (age 73 ± 10 years, 52% male) were included. Women showed more concentric hypertrophy and had more pronounced LV diastolic dysfunction than men. During a median follow-up of 34 (13-60) months, 682 (36%) deaths occurred. Men showed significantly higher mortality rates at 3- and 5-year follow-up (30% and 48%, respectively) than women (26% and 39%, respectively) (p = 0.011). On multivariable analysis, male sex remained independently associated with mortality (hazard ratio 1.209; 95% CI: 1.024-1.428; p = 0.025). LV remodeling (according to LV mass index) was associated with worse outcomes (hazard ratio 1.003; CI: 1.001-1.005; p = 0.006), but no association was observed between the interaction of LV mass index and sex with outcomes. ConclusionsLV remodeling patterns are different between men and women having moderate AS. Male sex is associated with worse outcomes in patients with medically treated moderate AS. Further studies investigating the management of moderate AS in a sex-specific manner are needed.

Prognostic value of cardiac magnetic resonance in patients with aortic stenosis: A systematic review and meta-analysis.

BackgroundThe timing of surgery for aortic stenosis (AS) is imperfect, and the management of moderate AS and asymptomatic severe AS is still challenging. Myocardial fibrosis (MF) is the main pathological basis of cardiac decompensation in patients with AS and can be detected by cardiovascular magnetic resonance (CMR). The aim of this study was to evaluate the prognostic value of MF measured by CMR in patients with AS, which can provide a reference for the timing of aortic valve replacement (AVR).MethodsWe searched Medline, Embase, and Web of Science to include all studies that investigated the prognostic value of CMR in patients with AS. The search deadline is March 31, 2021. The pooled relative risk (RR) or hazard ratio (HR) and 95% confidence intervals (CI) of the biomarkers including late gadolinium enhancement (LGE), Native T1 or extracellular volume (ECV) were calculated to evaluate the prognostic value.Results13 studies and 2,430 patients with AS were included in this study, the mean or medium follow-up duration for each study was ranged from 6 to 67.2 months. Meta-analysis showed the presence of LGE was associated with an increased risk for all-cause mortality (pooled RR: 2.14, 95% CI: 1.67–2.74, P < 0.001), cardiac mortality (pooled RR: 3.50, 95% CI: 2.32–5.30, P < 0.001), and major adverse cardiovascular events (MACEs) (pooled RR: 1.649, 95% CI: 1.23–2.22, P = 0.001). Native T1 was significantly associated with MACEs (pooled RR: 2.23, 95% CI: 1.00–4.95; P = 0.049), and higher ECV was associated with a higher risk of cardiovascular events (pooled HR: 1.69, 95% CI: 1.11–2.58; P = 0.014).ConclusionThe use of CMR to detect MF has a good prognostic value in patients with AS. LGE, Native T1 and ECV measured by CMR can contribute to risk stratification of AS, thereby helping to optimize the timing of AVR.

Diastolic Dysfunction Is Unmasked on Exercise in Patients With Asymptomatic, Severe Aortic Stenosis: An Invasive Hemodynamic Study.

Optimal timing of aortic valve replacement remains difficult in patients with asymptomatic, severe aortic stenosis (AS). More accurate diagnostic methods are warranted for the detection of subtle ventricular impairment. We aimed to evaluate diastolic function in asymptomatic patients with severe AS. In this cross-sectional study, patients with asymptomatic, severe AS were evaluated with right heart catheterization at rest and during moderate exercise. The patients also underwent cardiopulmonary exercise testing to objectify functional capacity and confirm the absence of symptoms. Between February 2019 and May 2021, we included 50 patients aged 70±12 years. The patients had severe AS with peak velocity 4.4±0.4 m/s, mean gradient 46±9 mm Hg, and an indexed valve area of 0.47±0.08 cm2 at rest. All patients were asymptomatic and had normal left ventricular ejection fraction. Five patients had postcapillary pulmonary hypertension at rest. During exercise, 44 patients (88%) had an increase in the mean pulmonary artery pressure per increase in cardiac output of >3 mm Hg/L per minute, of whom 93% had a concomitant increase in the pulmonary artery wedge pressure per increase in cardiac output >2 mm Hg/L per minute, suggesting exercise-induced pulmonary hypertension due to left heart disease. Female gender and increasing age were associated with a higher increase in the pulmonary artery wedge pressure per increase in cardiac output ratio. The catheterization was well tolerated, and there were no adverse events. A large proportion of asymptomatic patients with severe, degenerative AS have exercise-induced postcapillary pulmonary hypertension.

Cardiac Remodeling and Disease Progression in Patients With Repaired Coarctation of Aorta and Aortic Stenosis.

Valvulo-arterial impedance (Zva) is used for assessment of left ventricular (LV) global pressure load in patients with aortic stenosis (AS) and impaired arterial compliance. Because patients with repaired coarctation of aorta (COA) have impaired arterial compliance, we hypothesized that COA patients with greater than or equal to moderate AS (AS-COA group) will have higher Zva, symptomatic progression, and cardiovascular events, as compared to non-COA patients with similar AS severity (AS group). Propensity matching (1:1) of 71 AS-COA and 71 AS patients based on age, sex, body mass index, and aortic valve mean gradient (cohort 1). Of 172 patients, 117 patients (AS-COA [n=62]; AS [n=55]) underwent aortic valve replacement, cohort 2. Cohort 1 was used to assess the relationship between preoperative Zva, cardiac remodeling, and symptomatic progression, while cohort 2 was used to assess the relationship between postoperative Zva, LV mass index regression (reduction in LV mass index after aortic valve replacement), and cardiovascular events. The AS-COA group had higher Zva (4.2±0.6 versus 3.5±0.4 mm Hg/mL·m2, P<0.001), more advanced cardiac remodeling, and higher 5-year incidence of symptomatic progression (85% versus 51%, P<0.001). Preoperative Zva was independently associated with cardiac remodeling (r=0.66, P<0.001) and symptomatic progression (hazard ratio, 1.06 [1.02-1.10], per mm Hg/mL·m2 increase in Zva). The AS-COA group had higher postoperative Zva (3.3±0.5 versus 2.4±0.4 mm Hg/mL·m2, P<0.001), less robust LV mass index regression at 1-year post-aortic valve replacement, and higher 5-year incidence of cardiovascular events. Postoperative Zva was independently associated with LV mass index regression (r=-0.46, P<0.001) and cardiovascular events (hazard ratio, 1.06 [1.02-1.10], per mm Hg/mL·m2 increase in Zva). Adults with AS-COA had higher LV global pressure load, cardiac remodeling, symptomatic progression, and cardiovascular events as compared to non-COA patients with similar severity of AS. Zva can identify patients at risk for adverse outcomes, and perhaps should be used for risk stratification with regards to timing of aortic valve replacement.

Abstract 10305: Cardiac Remodeling and Disease Progression in Patients with Repaired Coarctation of Aorta and Aortic Stenosis

Introduction: Valvuloarterial impedance (Zva) is used for assessment of left ventricular (LV) global pressure load in patients with aortic stenosis (AS) and impaired arterial compliance. Since patients with coarctation of aorta (COA) have impaired arterial compliance, we hypothesized that COA patients with ≥moderate AS (AS-COA group) will have higher Zva, symptomatic progression, and cardiovascular events, as compared to non-COA patients with similar AS severity (AS group). Methods: 1:1 propensity matching of 71 AS-COA and 71 AS patients based on age, sex, body mass index, and aortic valve mean gradient. Results: The AS-COA group had higher Zva (4.2±0.6 vs 3.5±0.4 mmHg/ml*m 2 , p&lt;0.001), more advanced cardiac remodeling, and higher 5-year incidence of symptomatic progression (85% vs 51%, p&lt;0.001). Pre-operative Zva was independently associated with cardiac remodeling (r=0.66, p&lt;0.001) and symptomatic progression (HR 1.08, 1.05-1.12, per mmHg/ml*m 2 increase in Zva). Of 172 patients, 117 underwent aortic valve replacement (AVR). The AS-COA group had higher residual Zva(3.3±0.5 vs 2.4±0.4 mmHg/ml*m 2 , p&lt;0.001), less robust LV mass index (LVMI) regression at 1-year post-AVR, and higher 5-year incidence of cardiovascular events. Post-operative Zva was independently associated with LVMI regression (r=-0.46, p&lt;0.001) and cardiovascular events (HR 1.06, 1.02-1.10, per mmHg/ml*m 2 increase in Zva). Conclusions: Adults with repaired COA repair and moderate-severe AS had higher LV global pressure load, cardiac remodeling, symptomatic progression, and cardiovascular events as compared to non-COA patients with similar severity of AS. Zva can identify patients at risk for adverse outcomes, and perhaps should be used for risk stratification with regards to timing of AVR.

The association of left ventricular histologically verified myocardial fibrosis with pulmonary hypertension in severe aortic stenosis.

To evaluate the association between histologically verified left ventricular (LV) myocardial fibrosis (MF) and its bio- and functional markers with pulmonary hypertension (PH) in severe aortic stenosis (AS). About 34 patients with isolated severe AS underwent 2D echocardiography, cardiac magnetic resonance (CMR) imaging, and plasma NT-proBNP evaluation before aortic valve replacement (AVR). LV measurements were analyzed by CMR and LV strain using feature tracking software (Medis Suite QStrain 2.0). Myocardial biopsy sampled at the time of AVR was assessed by a histomorphometric analysis. PH was defined as pulmonary artery systolic pressure (PASP) ⩾ 45 mm Hg. Patients with severe AS and PH (mean PASP 53 ± 3.7 mm Hg) had higher extent of diffuse MF versus patients without PH (12 (10.4-12.7)% vs 6.6 (4.6-8.2)% (p = 0.00)). The extent of diffuse MF correlated with LV dilatation (r = 0.7, p = 0.02), indices of LV dysfunction (lower ejection fraction (r = -0.6, p < 0.001), global longitudinal (r = -0.5, p = 0.02) and circumferential strain (r = -0.5, p = 0.05), elevated NT-proBNP (r = 0.5, p = 0.005) and elevated PASP (r = 0.6, p < 0.001)). Histological MF > 10% (AUC 94.9%), LV global longitudinal strain > -15.5% (AUC 86.3%), and NT-proBNP > 2090 ng/l (AUC 85.1%) were independent predictors of PH in severe AS. The extent of diffuse myocardial fibrosis in combination with reduced longitudinal left ventricular strain and increased plasma levels of NT-proBNP relates to pulmonary hypertension in severe aortic stenosis.