Untreated Severe Aortic Stenosis Research Articles

Protecting the vulnerable during a crisis - TAVR during the COVID-19 pandemic

Abstract Introduction The coronavirus (COVID-19) pandemic has been challenging for healthcare systems globally. Patients with symptomatic severe aortic stenosis awaiting transcatheter aortic valve replacement (TAVR) are a vulnerable, elderly subset of patients often with multiple comorbidities. Untreated severe aortic stenosis (AS) is associated with a poor prognosis. It is uncertain if population-based strategies to mitigate COVID-19 spread such as delaying elective procedures and virtual consultations have resulted in increased morbidity or mortality in this subset of patients. Position statements guiding TAVR during the COVID-19 pandemic have suggested fewer and shorter hospital admissions. We evaluated the available literature and performed a systematic review and meta-analysis assessing the impact of the COVID-19 pandemic on referral times, hospital stays and mortality in patients awaiting TAVR. Methods This systematic review and meta-analysis (CRD42022379840) is reported according to PRISMA guidelines. A comprehensive search strategy with computer- based search was performed using PubMed, Ovid MEDLINE, EMBASE and Cochrane databases. No time limit to start date was applied, and the search was conducted up to 28 November 2022. Only studies with available comparative data to pre-COVID 19 cohorts were included. Results Eleven studies satisfied our inclusion criteria, with a pooled analysis of 79785 TAVR patients. Patients undergoing TAVR in the COVID-19 era were associated with a modest risk of all-cause mortality (unadjusted RR: 1.41, 95% CI 0.97-2.06) however this was not statistically significant (Figure 1) and substantial heterogeneity was observed (p<0.01 and i2 = 84%). Patients undergoing TAVR in the COVID-19 cohort trended towards shorter average lengths of stay and time from referral to procedure than TAVR patients prior to the pandemic (mean difference -0.37, 95% CI -0.93 – 0.19 and mean difference -25.43, 95% CI -52.31 to 1.44 respectively), however this was not significant. Conclusion This systematic review suggested a trend towards increased all-cause mortality in TAVR patients in the COVID-19 era. Furthermore, the available data trended towards shorter times from referral to TAVR and a shorter average length of stay, consistent with published recommendations from European and Asian expert consensus papers. Our data did not reach statistical significance and showed significant heterogeneity, likely reflecting widespread institutional variations during the pandemic. As the COVID-19 dynamic changes, further data is required to help characterise and optimise patient care in this vulnerable patient group.

Very acute benefits on physical performance in elderly patients who undergone TAVI

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Transcatheter aortic valve implantation (TAVI) emerged as a safe and efficient procedure in patients with high or prohibitive surgical risk or in older patients. The prevalence of severe aortic stenosis is growing up, given de aging of population. These patients are much often frailty and experience low levels of physical activity and functional capacity as a result of their aortic valve disease and comorbidities. When untreated severe aortic stenosis has a poor prognosis so it is of utmost importance to restore the normal hemodynamic condition and consequently to improve functional capacity. Aim To assess the acute benefits (in 1 moth) of TAVI on functional capacity and physical performance. Methods Single center prospective study of patients submitted to TAVi between April 2021 and September 2021. Patients were evaluated at baseline (before TAVI) and one month after the procedure. To assess physical activity and functional capacity it was used the International Physical Activity Questionnaire (IPAQ) and the short physical performance battery (SPPB) which is a group of measures that combines the results of the gait speed (two timed trials of a 4-m walk – fastest recorded), chair stand (time to raise for a chair 5 times) and balance tests (ability to stand for 10 seconds with feet in 3 different positions). Additionally, patients were submitted to handgrip strength test. Paired sample t-test and Wilcoxon test were used to statistical analysis. Results We included 20 patients, with a mean age of 85±5,86 years, 40% (8) male. 19 patients undergone TAVI due severe native aortic stenosis and 1 due to bioprosthetic aortic valve dysfunction. The vascular access site was transfemoral in 19 patients and transapical in 1 patient. No patient had vigorous physical activity either before or after TAVI, but the daily sitting time was lower after the procedure (mean time: 634 versus 570 minutes), however not statistically significant. Regarding the results of SPPB patients experience improvements in balance (p=0,035) and chair stand (time to raise for a chair 5 times: 19,04 versus 17,05 seconds), p=0,01. Patients tended to be faster in 4m velocity test, however with no statistical difference (8,49 versus 6,6 seconds). No statistical differences were also observed in handgrip strength test. Conclusion In an elderly population, TAVI appears to have an early and beneficial effect (in 1 moth) on some domains oh physical activity and functional capacity.

Predictors of increased mortality in untreated moderate aortic stenosis

Abstract Background The natural history of native valvular moderate aortic stenosis (AS) is poorly understood. Purpose To examine the prognosis of patients with native valvular moderate AS, and identify high risk-features associated with increased mortality. Methods Natural language processing of electronic health records in the claims-linked Optum® database (2011–2018) from over 200 hospitals and 7000 clinics in the United States identified severity of AS (mild/moderate/severe) from echocardiograms and physician notes of patients more than 65 years old. Our cohort included 30,204 patients (3594 with mild, 9938 with moderate, and 16672 with severe AS). We used competing risk Kaplan-Meier analysis to compare 5-year mortality (obtained from the Social Security Death Masterfile) between the different AS severity groups adjusted for demographics and comorbidities, censoring for aortic valve replacement. The relationship between AS severity and survival was examined during median 1049 days (interquartile range: 597 to 1652 days) of follow-up. We performed Fine-Gray modeling to examine risk factors associated with long-term mortality in patients with moderate AS. Results A higher proportion of comorbidities like atrial fibrillation, diabetes, and coronary artery disease were observed with increasing severity of AS (Figure 1). After adjustment, compared with mild AS (5-year mortality: 31.6%), patients with untreated moderate (5-year mortality: 40.0%, HR 1.34, 95% CI 1.25 – 1.44) and untreated severe AS (5-year mortality: 51.1%, HR 1.88, 95% CI 1.75– 2.01) have increasing risk of long-term mortality (Figure 2). Significant predictors of 5-year mortality in patients with moderate AS include older age (HR 1.38, 95% CI 1.29 –1.47), male sex (HR 1.21, 95% CI 1.15 – 1.27), heart failure (HR 1.37, 95% CI 1.29 – 1.44), coronary artery disease (HR 1.20, 95% CI 1.13 – 1.27), and atrial fibrillation (HR 1.08, 95% CI 1.02 – 1.14). In a subcohort of 5189 patients for whom left ventricular ejection fraction (LVEF) information was available, reduced LVEF was associated with worse long-term mortality (LVEF<40%: HR 1.17, 95% CI 1.05 –1.31; LVEF 40–50%: HR 1.08, 95% CI 0.97 –1.20). Conclusion Our findings suggest that moderate AS is associated with poor long-term survival with higher risk associated with LVEF <40%, and comorbidities including heart failure, coronary artery disease and atrial fibrillation. Whether patients with moderate AS, particularly with high-risk features, benefit from treatment remains unknown. Funding Acknowledgement Type of funding sources: None. Baseline CharacteristicsAdjusted KM curves with Competing Risk

THE TUNNEL-VISION EFFECT OF COVID-19: AN INCIDENTAL DISCOVERY OF SEVERE BICUSPID AORTIC VALVE STENOSIS

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Bicuspid aortic valve is the most common congenital valvular abnormality, and has an autosomal dominant pattern with incomplete penetrance. Early recognition in the outpatient setting is imperative to prevent the development of aortic stenosis, particularly before it becomes severe. Once the disease progresses to end stage, patients may begin to experience dyspnea on exertion, syncope, and orthopnea. CASE PRESENTATION: We present a case of a 52-year-old male with complaints of shortness of breath, retrosternal chest pain, and nonproductive cough. His dyspnea began 3 months ago, but have progressed to where he felt dyspneic at rest 6 hours prior to admission. He had a positive SARS-CoV-2 PCR two weeks prior at an ancillary testing site. He worked as an iron welder for 37 years, and stated that he hasn't seen a physician in years. Despite a negative SARS-CoV-2 PCR in the ED, he was placed in negative pressure isolation. His initial vitals were BP 114/84, HR 124, RR 36, SpO2 91% on room air, and temperature 102.2 F. There was a loud systolic murmur over the precordium (clearly audible over the ventilation equipment), bibasilar rhonchi on auscultation, minimally elevated JVD, and no bipedal edema. Labs revealed a troponin of 0.152 ng/dL and proBNP 2020 pg/mL, and CXR AP view showed an enlarged cardiac silhouette and minimal bibasilar infiltrate. EKG revealed sinus tachycardia of 120 bpm and LBBB. He was given IVF and IV antibiotics for suspected sepsis due to superimposed bacterial pneumonia. Transthoracic echocardiogram revealed severe bicuspid aortic valve stenosis (velocity 4.01 m/sec, mean PG 42.8 mm Hg, and AVA di 0.75 cm2) and LVEF 30-35%. The following morning, the patient went into flash pulmonary edema requiring urgent intubation and mechanical ventilation. Surprisingly, his repeat SARS-CoV-2 PCR was positive, however his clinical picture was more suggestive of decompensated heart failure rather than active COVID-19. He was aggressively diuresed and extubated 3 days later, and was successfully discharged home with close follow up for possible surgical intervention. DISCUSSION: Bicuspid aortic valve is one of the most significant risk factors leading to severe aortic stenosis (1). Symptoms may remain clinically silent for years, and usually occur only when there is an increase in LVEDP (1). In our case, the patient's recent diagnosis of COVID-19 two weeks prior was a smoke screen of his more insidious underlying valvulopathy. Luckily, he did not succumb to COVID-19, as an international registry of 74 patients with untreated severe aortic stenosis who developed COVID-19 had a mortality of 59.5% and 23.5% for those older and less than 80 years, respectively (2). CONCLUSIONS: It is imperative that we as clinicians remain vigilant and avoid becoming fixated on COVID-19 and its complications, as this may obscure an underlying disease with harmful repercussions if left untreated. REFERENCE #1: Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, O'Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM 3rd, Thomas JD;American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Jun 10;63(22):e57-185. doi: 10.1016/j.jacc.2014.02.536. Epub 2014 Mar 3. Erratum in: J Am Coll Cardiol. 2014 Jun 10;63(22):2489. PMID: 24603191. REFERENCE #2: Danny Dvir, Matheus Simonato, Ignacio Amat-Santos, Azeem Latib, Faraj Kargoli, Luis Nombela-Franco, Marco Agrifoglio, Francesco Giannini, Damiano Regazzoli, Bernhard Reimers, Emmanuel Villa, Victor M. Becerra-Munoz, Marco Mennuni, Andrea Rognoni, Thomas Modine, Lionel Leroux, Rodrigo Estevez-Loureiro, Roberto Nerla, Fausto Castriota, Alfredo Cerillo, Lars Sondergaard, Alessandro Iadanza, Alison Duncan, Flavien Vincent, Massimo Mancone, Lucia Bi tolo, Viviana Maestrini, Luca Testa, Wojtek Wojakowski, Stefano Salizzoni, Vinicius Esteves, Fernanda Mangione, Cleverson Zukowski, Nicolas Amabile, Mony Shuvy & Gregg W. Stone (2021) Severe Valvular Heart Disease and COVID-19: Results from the Multicenter International Valve Disease Registry, Structural Heart, DOI: 10.1080/24748706.2021.1908646 DISCLOSURES: No relevant relationships by Maie Abdullah, source=Web Response No relevant relationships by Nabil Braiteh, source=Web Response No relevant relationships by Kareem Ebeid, source=Web Response No relevant relationships by Altif Muneeb, source=Web Response No relevant relationships by Fnu Shailesh, source=Web Response

Balloon Aortic Valvuloplasty

When balloon aortic valvuloplasty (BAV) was first developed 30 years ago, it offered an alternative to conventional surgical aortic valve replacement in elderly and frail patients for whom there were no other effective options. Initial excitement at its dramatic hemodynamic and symptomatic benefits was tempered when it was established that the hemodynamic improvement was short lived with rapid restenosis, and patients had the same very poor outcome as those with untreated severe aortic stenosis.1–4 More recently, in the PARTNER study (Placement of Aortic Transcatheter Valve), which defined the start of the transcatheter aortic valve replacement (TAVR) era, most patients randomized to standard treatment underwent BAV. Again, there was an initial improvement in symptoms and survival compared with patients not undergoing BAV, but after 1 year, there was no difference between the groups.5 Despite these findings, BAV has staged a resurgence in recent years, as a standalone palliative therapy in patients unfit for surgery or as a bridge to definitive treatment with TAVR or conventional surgical aortic valve replacement. It is important that we understand why BAV use has increased, and whether this increase is justified. See Article by Alkhouli et al In this issue of Circulation: Cardiovascular Interventions , Alkhouli et al6 provide a timely update on the utilization and outcomes of BAV using data from the National Inpatient Sample, a database of US hospital discharges from hospitals from the Healthcare Cost and Utilization project. They analyze BAV use and outcomes over 10 years (2004–2013) which include the beginning of the TAVR era. The authors addressed 3 important …

AS-61: Untreated Severe Aortic Stenosis Is Associated with Poor Outcomes: Should We Change the Practice?

AS-61: Untreated Severe Aortic Stenosis Is Associated with Poor Outcomes: Should We Change the Practice?

TCT-116: Outcomes of Patients with Untreated Severe Aortic Stenosis(AS) in Real World Practice

TCT-116: Outcomes of Patients with Untreated Severe Aortic Stenosis(AS) in Real World Practice

Untreated Severe Aortic Stenosis (AS) is Associated with Poor Outcomes

Untreated Severe Aortic Stenosis (AS) is Associated with Poor Outcomes

Untreated severe aortic stenosis (AS) is associated with poor outcomes

Untreated severe aortic stenosis (AS) is associated with poor outcomes

Balloon aortic valvuloplasty

Balloon aortic valvuloplasty is a percutaneous, therapeutic option for patients with severe aortic stenosis, yet the effectiveness of this procedure is dependent on the morphology of the stenotic aortic valve and the respective mechanism of dilation. In younger patients with congenital aortic stenosis, acute and intermediate-term results are good. However, in adult patients, in whom degenerative aortic stenosis is the most common cause, the acute clinical and hemodynamic benefits of balloon aortic valvuloplasty are not lasting, as restenosis occurs in most patients within 6 months. Sympatomatic relief for adults undergoing balloon aortic valvuloplasty is only apparent in patients with normal left ventricular function, who generally are also candidates for aortic valve replacement. Furthermore, the long-term survival for adults after balloon aortic valvuloplasty is similar to the natural history of untreated severe aortic stenosis. In this article, the mechanism of balloon aortic valvuloplasty, as well as its clinical and hemodynamic effects, are reviewed in the context of the different morphological types of aortic stenosis. In addition, two large registries of adult patients treated with balloon aortic valvuloplasty provide important information regarding the acute and long-term results of this procedure and are reviewed.