101
|
Essayagh B, Sabbag A, Antoine C, Benfari G, Batista R, Yang L, Maalouf J, Asirvatham S, Michelena H, Enriquez-Sarano M. The mitral annulus disjunction of mitral valve prolapse: Presentation and outcome. ARCHIVES OF CARDIOVASCULAR DISEASES SUPPLEMENTS 2021. [DOI: 10.1016/j.acvdsp.2021.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
102
|
Essayagh B, Benfari G, Antoine C, Maalouf J, Enriquez-Sarano M. Atrial coupling index by standard echocardiography in Degenerative Mitral Regurgitation: An incremental determinant of survival. ARCHIVES OF CARDIOVASCULAR DISEASES SUPPLEMENTS 2021. [DOI: 10.1016/j.acvdsp.2021.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
103
|
Kar S, Mack MJ, Lindenfeld J, Abraham WT, Asch FM, Weissman NJ, Enriquez-Sarano M, Lim DS, Mishell JM, Whisenant BK, Rogers JH, Arnold SV, Cohen DJ, Grayburn PA, Stone GW. Relationship Between Residual Mitral Regurgitation and Clinical and Quality-of-Life Outcomes After Transcatheter and Medical Treatments in Heart Failure: COAPT Trial. Circulation 2021; 144:426-437. [PMID: 34039025 DOI: 10.1161/circulationaha.120.053061] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In the randomized COAPT trial (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation), among 614 patients with heart failure with 3+ or 4+ secondary mitral regurgitation (MR), transcatheter mitral valve repair (TMVr) with the MitraClip reduced MR, heart failure hospitalizations, and mortality and improved quality of life compared with guideline-directed medical therapy (GDMT) alone. We aimed to examine the prognostic relationship between MR reduction and outcomes after TMVr and GDMT alone. METHODS Outcomes in COAPT between 30 days and 2 years were examined on the basis of the severity of residual MR at 30 days. RESULTS TMVr-treated patients had less severe residual MR at 30 days than GDMT-treated patients (0/1+, 2+, and 3+/4+: 72.9%, 19.9%, and 7.2% versus 8.2%, 26.1%, and 65.8%, respectively [P<0.0001]). The rate of composite death or heart failure hospitalizations between 30 days and 2 years was lower in patients with 30-day residual MR of 0/1+ and 2+ compared with patients with 30-day residual MR of 3+/4+ (37.7% versus 49.5% versus 72.2%, respectively [P<0.0001]). This relationship was consistent in the TMVr and GDMT arms (Pinteraction=0.92). The improvement in Kansas City Cardiomyopathy Questionnaire score from baseline to 30 days was maintained between 30 days and 2 years in patients with 30-day MR ≤2+ but deteriorated in those with 30-day MR 3+/4+ (-0.3±1.7 versus -9.4±4.6 [P=0.0008]) consistently in both groups (Pinteraction=0.95). CONCLUSIONS In the COAPT trial, reduced MR at 30 days was associated with greater freedom from death or heart failure hospitalizations and improved quality of life through 2-year follow-up whether the MR reduction was achieved by TMVr or GDMT. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01626079.
Collapse
|
104
|
Cahill TJ, Prothero A, Wilson J, Kennedy A, Brubert J, Masters M, Newton JD, Dawkins S, Enriquez-Sarano M, Prendergast BD, Myerson SG. Community prevalence, mechanisms and outcome of mitral or tricuspid regurgitation. Heart 2021; 107:1003-1009. [PMID: 33674352 DOI: 10.1136/heartjnl-2020-318482] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The study aims were (1) to identify the community prevalence of moderate or greater mitral or tricuspid regurgitation (MR/TR), (2) to compare subjects identified by population screening with those with known valvular heart disease (VHD), (3) to understand the mechanisms of MR/TR and (4) to assess the rate of valve intervention and long-term outcome. METHODS Adults aged ≥65 years registered at seven family medicine practices in Oxfordshire, UK were screened for inclusion (n=9504). Subjects with known VHD were identified from hospital records and those without VHD invited to undergo transthoracic echocardiography (TTE) within the Oxford Valvular Heart Disease Population Study (OxVALVE). The study population ultimately comprised 4755 subjects. The severity and aetiology of MR and TR were assessed by integrated comprehensive TTE assessment. RESULTS The prevalence of moderate or greater MR and TR was 3.5% (95% CI 3.1 to 3.8) and 2.6% (95% CI 2.3 to 2.9), respectively. Primary MR was the most common aetiology (124/203, 61.1%). Almost half of cases were newly diagnosed by screening: MR 98/203 (48.3%), TR 69/155 (44.5%). Subjects diagnosed by screening were less symptomatic, more likely to have primary MR and had a lower incidence of aortic valve disease. Surgical intervention was undertaken in six subjects (2.4%) over a median follow-up of 64 months. Five-year survival was 79.8% in subjects with isolated MR, 84.8% in those with isolated TR, and 59.4% in those with combined MR and TR (p=0.0005). CONCLUSIONS Moderate or greater MR/TR is common, age-dependent and is underdiagnosed. Current rates of valve intervention are extremely low.
Collapse
|
105
|
Ye Z, Smith MM, Jouni H, Geske JB, Carney SA, Urina-Jassir M, Schaff HV, Enriquez-Sarano M, Michelena HI. Mitral Valve Cleft-like Indentations in Hypertrophic Obstructive Cardiomyopathy: Insights From Intraoperative Three-Dimensional Transesophageal Echocardiography. J Cardiothorac Vasc Anesth 2021; 36:429-436. [PMID: 34176680 DOI: 10.1053/j.jvca.2021.05.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/15/2021] [Accepted: 05/19/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Cleft-like indentations (CLIs) of the mitral valve (MV) are best assessed with three-dimensional (3D) transesophageal echocardiography (TEE). The present study examined the prevalence, characteristics, and surgical effect of MV CLIs in patients with hypertrophic cardiomyopathy (HCM). DESIGN Prospective, observational, case-control study. SETTING Tertiary medical center. PARTICIPANTS The study comprised 90 patients with HCM undergoing myectomy and 59 patients undergoing cardiac surgery for non-MV related indications. MEASUREMENTS AND MAIN RESULTS Intraoperative 3D TEE was used to evaluate the presence and characteristics of MV CLIs compared, with a random control group of 59 patients undergoing cardiac surgery for non-MV related indications. Ninety patients with HCM (mean age 54.8 ± 13.3 y, 67.8% male) were compared with 59 control patients (mean age 67 ± 12.7 y, 79.7% male). Three-dimensional TEE images were interpreted by consensus of two experienced echocardiographers. At least one MV CLI was present in 84 patients with HCM (93.3%), compared with 23 control patients (39%; p < 0.01). Compared with control patients, patients with HCM were more likely to have deep MV CLIs (85.6% v 25.4%; p < 0.01) and ≥2 CLIs (52.2% v 26.1%; p = 0.02). Six HCM patients (7%) appeared to have true congenital posterior leaflet clefts versus 0% in control patients (p = 0.08). Preoperative mitral regurgitation severity and jet direction were not associated with the presence of deep or multiple MV CLIs (all p > 0.2). None of the MV CLIs in the HCM group required MV surgical intervention or second pump runs for MV regurgitation correction after myectomy. CONCLUSION Deep and multiple MV CLIs are common in patients with HCM undergoing septal myectomy, including possible true posterior clefts, but they are not associated with the premyectomy severity of mitral regurgitation or jet direction, and do not result in surgical MV intervention.
Collapse
|
106
|
Cohen-Shelly M, Attia ZI, Friedman PA, Ito S, Essayagh BA, Ko WY, Murphree DH, Michelena HI, Enriquez-Sarano M, Carter RE, Johnson PW, Noseworthy PA, Lopez-Jimenez F, Oh JK. Electrocardiogram screening for aortic valve stenosis using artificial intelligence. Eur Heart J 2021; 42:2885-2896. [PMID: 33748852 DOI: 10.1093/eurheartj/ehab153] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 12/22/2020] [Accepted: 03/04/2021] [Indexed: 12/19/2022] Open
Abstract
AIMS Early detection of aortic stenosis (AS) is becoming increasingly important with a better outcome after aortic valve replacement in asymptomatic severe AS patients and a poor outcome in moderate AS. We aimed to develop artificial intelligence-enabled electrocardiogram (AI-ECG) using a convolutional neural network to identify patients with moderate to severe AS. METHODS AND RESULTS Between 1989 and 2019, 258 607 adults [mean age 63 ± 16.3 years; women 122 790 (48%)] with an echocardiography and an ECG performed within 180 days were identified from the Mayo Clinic database. Moderate to severe AS by echocardiography was present in 9723 (3.7%) patients. Artificial intelligence training was performed in 129 788 (50%), validation in 25 893 (10%), and testing in 102 926 (40%) randomly selected subjects. In the test group, the AI-ECG labelled 3833 (3.7%) patients as positive with the area under the curve (AUC) of 0.85. The sensitivity, specificity, and accuracy were 78%, 74%, and 74%, respectively. The sensitivity increased and the specificity decreased as age increased. Women had lower sensitivity but higher specificity compared with men at any age groups. The model performance increased when age and sex were added to the model (AUC 0.87), which further increased to 0.90 in patients without hypertension. Patients with false-positive AI-ECGs had twice the risk for developing moderate or severe AS in 15 years compared with true negative AI-ECGs (hazard ratio 2.18, 95% confidence interval 1.90-2.50). CONCLUSION An AI-ECG can identify patients with moderate or severe AS and may serve as a powerful screening tool for AS in the community.
Collapse
|
107
|
Yang LT, Boler A, Medina-Inojosa JR, Scott CG, Maurer MJ, Eleid MF, Enriquez-Sarano M, Tribouilloy C, Michelena HI. Aortic Stenosis Progression, Cardiac Damage, and Survival: Comparison Between Bicuspid and Tricuspid Aortic Valves. JACC Cardiovasc Imaging 2021; 14:1113-1126. [PMID: 33744153 DOI: 10.1016/j.jcmg.2021.01.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/21/2020] [Accepted: 01/11/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES This study sought to compare aortic stenosis (AS) progression rates, AS-related cardiac damage (AS-CD) indicator incidence and determinants, and survival between patients with tricuspid aortic valve (TAV)-AS and those with bicuspid aortic valve (BAV)-AS. BACKGROUND Differences in AS progression and AS-CD between patients with BAV and patients with TAV are unknown. METHODS We retrospectively studied consecutive patients with baseline peak aortic valve velocity (peakV) ≥2.5 m/s and left ventricular ejection fraction ≥50%. Follow-up echocardiograms (n = 4,818) provided multiparametric AS progression rates and AS-CD. RESULTS The study included 330 BAV (age 54 ± 14 years) and 581 patients with TAV (age 72 ± 11 years). At last echocardiogram (median: 5.9 years; interquartile range: 3.9 to 8.5 years), BAV-AS exhibited similar peakV and mean pressure gradient (MPG) as TAV-AS, but larger calculated aortic valve area due to larger aortic annulus (p < 0.0001). Multiparametric progression rates were similar between BAV-AS and TAV-AS (all p ≥ 0.08) and did not predict age-/sex-adjusted survival (p ≥ 0.45). Independent determinants of rapid progression were male sex and baseline AS severity for TAV (all p ≤ 0.024), and age, baseline AS severity, and cardiac risk factors (age interaction: p = 0.02) for BAV (all p ≤ 0.005). At 12 years, patients with TAV-AS had a higher incidence of AS-CD than BAV-AS patients (p < 0.0001), resulting in significantly worse survival compared to BAV-AS (p < 0.0001). AS-CD were independently determined by multiple factors (MPG, age, sex, comorbidities, cardiac function; all p ≤ 0.039), and BAV was independently protective of most AS-CD (all p ≤ 0.05). CONCLUSIONS In this cohort, TAV-AS and BAV-AS progression rates were similar. Rapid progression did not affect survival and was determined by cardiac risk factors for BAV-AS (particularly in patients with BAV <60 years of age) and unmodifiable factors for TAV-AS. AS-CD and mortality were significantly higher in TAV-AS. Independent determinants of AS-CD were multifactorial, and BAV morphology was AS-CD protective. Therefore, the totality of AS burden (cardiac damage) is clinically crucial for TAV-AS, whereas attention to modifiable risk factors may be preventive for BAV-AS.
Collapse
|
108
|
Lopes BBC, Sorajja P, Hashimoto G, Fukui M, Bapat VN, Du Y, Bae R, Schwartz RS, Stanberry LI, Enriquez-Sarano M, Garcia SA, Lesser JR, Cavalcante JL. Tricuspid Anatomic Regurgitant Orifice Area by Functional DSCT: A Novel Parameter of Tricuspid Regurgitation Severity. JACC Cardiovasc Imaging 2021; 14:1669-1672. [PMID: 33744143 DOI: 10.1016/j.jcmg.2021.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/29/2021] [Accepted: 02/01/2021] [Indexed: 11/25/2022]
|
109
|
Du Y, Gössl M, Garcia S, Enriquez-Sarano M, Cavalcante JL, Bae R, Hashimoto G, Fukui M, Lopes B, Ahmed A, Schmidt C, Stanberry L, Garberich R, Bradley SM, Steffen R, Sorajja P. Natural history observations in moderate aortic stenosis. BMC Cardiovasc Disord 2021; 21:108. [PMID: 33607944 PMCID: PMC7893941 DOI: 10.1186/s12872-021-01901-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 01/30/2021] [Accepted: 02/02/2021] [Indexed: 12/14/2022] Open
Abstract
Background The natural history of patients with moderate aortic stenosis (AS) is poorly understood. We aimed to determine the long-term outcomes of patients with moderate AS. Methods
We examined patients with moderate AS defined by echocardiography in our healthcare system, and performed survival analyses for occurrence of death, heart failure (HF) hospitalization, and progression of AS, with accounting for symptoms, left ventricular dysfunction, and comorbidities. Results We examined 729 patients with moderate AS (median age, 76 years; 59.9 % men) with a median follow-up of 5.0 years (interquartile range: 2.0 to 8.1 years). The 5-year overall survival was 52.3 % (95 % confidence interval [CI]: 48.6 % to 56.0 %) and survival free of death or HF hospitalization was 43.2 % (95 % CI: 39.5 % to 46.9 %). Worse New York Heart Association (NYHA) functional class was associated with poor long-term survival, with mortality rates ranging from 7.9 % (95 % CI: 6.6–9.2 %) to 25.2 % (95 % CI: 20.2–30.3 %) per year. Among patients with minimal or no symptoms, no futility markers, and preserved left ventricular function, 5-year overall survival was 71.9 % (95 % CI: 66.4–77.4 %) and survival free of death or HF hospitalization was 61.4 % (95 % CI: 55.5–67.3 %). Risk factors associated with adverse events were age, NYHA class, low ejection fraction and high aortic valve velocity (all p < 0.05). Conclusions Patients with moderate AS are at significant risk of death. Our findings highlight the need for more study into appropriate therapeutic interventions to improve the prognosis of these patients.
Collapse
|
110
|
Lopes BBC, Kwon DH, Shah DJ, Lesser JR, Bapat V, Enriquez-Sarano M, Sorajja P, Cavalcante JL. Importance of Myocardial Fibrosis in Functional Mitral Regurgitation: From Outcomes to Decision-Making. JACC Cardiovasc Imaging 2021; 14:867-878. [PMID: 33582069 DOI: 10.1016/j.jcmg.2020.10.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/19/2020] [Accepted: 10/08/2020] [Indexed: 12/27/2022]
Abstract
Functional mitral regurgitation (FMR) is a common and complex valve disease, in which severity and risk stratification is still a conundrum. Although risk increases with FMR severity, it is modulated by subjacent left ventricular (LV) disease. The extent of LV remodeling and dysfunction is traditionally evaluated by echocardiography, but a growing body of evidence shows that myocardial fibrosis (MF) assessment by cardiac magnetic resonance (CMR) may complement risk stratification and inform treatment decisions. This review summarizes the current knowledge on the comprehensive evaluation that CMR can provide for patients with FMR, in particular for the assessment of MF and its potential impact in clinical decision-making.
Collapse
|
111
|
Fukui M, Hashimoto G, Lopes B, Du Y, Stanberry L, Garcia S, Goessl M, Enriquez-Sarano M, Bapat V, Sorajja P, Lesser J, Cavalcante J. Computed tomography derived left ventricular global longitudinal strain associate with clinical outcomes in patients undergoing transcatheter aortic valve replacement. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeaa356.226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Computed tomography angiography (CTA) is key imaging modality for procedure planning for transcatheter aortic valve replacement (TAVR). Functional assessment by CTA with LV global longitudinal strain (LVGLS) has recently shown to be feasible. However, there is limited data on its prognostic value in patients with severe aortic stenosis (AS) who treated with TAVR.
Purpose
To evaluate the association of baseline CTA-LVGLS with post-TAVR outcome.
Methods
Patients who underwent contrast multiphasic gated CTA for TAVR planning were studied. LVGLS was measured using dedicated feature-tracking software (Medis®). Cox regression analysis evaluated the association of baseline LVGLS with a composite outcome of all-cause death and heart failure hospitalization after TAVR.
Results
A total of 431 patients were included (median [IQR] age, 83 [77,87]years; 44% female); the society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score, 3.3 [2.3,5.1]%; CTA-LVGLS, -18.0 [-21.6,-14.2]%; LV ejection fraction was preserved at 60 [55,65]%. After a median follow-up of 19 [13,27] months, 99 composite outcomes occurred after TAVR. On multivariable Cox regression analysis, LVGLS was associated with the risk of composite outcome even after adjustment for baseline characteristics (Figure A). Patients with reduced LVGLS (above the median >-18.0%) had higher risk of the composite outcome than those with preserved GLS (p = 0.003; Figure B).
Conclusion
Baseline CTA-LVGLS was associated with the risk of death or heart failure hospitalization over the clinical and echocardiographic characteristics in severe AS patients undergoing TAVR.
Abstract Figure.
Collapse
|
112
|
Essayagh B, Benfari G, Antoine C, Batista R, Maalouf J, Michelena H, Enriquez-Sarano M. Atrial coupling index by standard echocardiography in degenerative mitral regurgitation: incremental determinant of survival. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeaa356.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Public hospital(s). Main funding source(s): Mayo Clinic Foundation
Background
Left atrial (LA) volume is linked to outcome in degenerative mitral regurgitation (DMR) but does not encompass LA function assessment. Thus, we ought to determine the prognostic role of left atrial coupling-index (LACI), as left atrial volume-index (LAVI) by Tissue-Doppler-Imaging a’ (TDI-a’), in a large cohort of DMR.
Methods
All consecutive 4792 patients (61 ± 16 years, 48% women) with isolated degenerative mitral valve disease diagnosed at Mayo Clinic 2003-2011, comprehensively characterized, in whom LAVI and TDI-a’ in sinus rhythm was prospectively measured in routine practice, was enrolled and their long-term survival analyzed.
Results
LACI (5.8 ± 3.7–T1 < 3.8; T2 3.8-6.3; T3 > 6.3) was significantly higher through different DMR grades (no, mild, moderate, severe DMR: 3.77 ± 2.26, 5.08 ± 2.95, 6.54 ± 3.74 and 7.84 ±4.29 respectively; p < 0.0001). Independent determinants of LA dysfunction assessed by LACI were age, E/e’, left-ventricle (LV) end-systolic-diameter, mitral-regurgitation (MR) grade, and LV ejection-fraction (all P ≤ 0.0001). LACI > 6 was independently associated with dyspnea, edema, more severe functional tricuspid-regurgitation and elevated pulmonary artery pressure, irrespective of age, sex, Charlson-comorbidity-index, ventricular function and MR severity. Total follow-up was 7.03 ± 3.0 years, during which 1146 (24%) underwent mitral-valve surgery (94% repair-6% replacement) and 880 (18%) died, 780 under medical treatment and 100 after surgery. Overall survival throughout follow-up (10-year 76 ± 1%) was strongly associated with LACI (88 ± 1% vs. 78 ± 1% and 62 ± 2% for LACI <3.8, 3.8-6.3 and ≥6.3, P < 0.0001) even adjusting comprehensively, including for DMR severity (adjusted-hazard-ratio 1.23[1.07-1.43] for LACI > 5.79, P = 0.005). Mortality under medical management was profoundly affected by LACI (adjusted-hazard-ratio 1.11[1.05-1.18] per 3 unit increment; 1.35[1.15-1.58] for LACI > 5.79 vs. ≤5.79, both P = 0.0002). Survival improved after mitral surgery (time-dependent adjusted-hazard-ratio 0.40[0.28-0.65], P < 0.0001) but remained humbly linked to LACI (10-year 93 ± 3% vs. 90 ± 2% and 80 ± 3% for LACI tertiles, P = 0.0008). Most importantly, LACI provided incremental prognostic information over LAVI and other conventional determinants of survival (P < 0.0001) with Net-reclassification-improvement vs. LAVI of 0.21 ± 0.02, P < 0.0001.
Conclusion
LA function assessed by LACI in routine practice, by conventional echocardiographic measurements, displays incremental and independent link to excess-mortality, considerable under medical management and partially alleviated by mitral surgery. Thus, LACI is a simple tool of crucial interest in DMR risk-stratification.
Abstract Figure. LACI in DMR
Collapse
|
113
|
Yang LT, Anand V, Zambito EI, Pellikka PA, Scott CG, Thapa P, Padang R, Takeuchi M, Nishimura RA, Enriquez-Sarano M, Michelena HI. Association of Echocardiographic Left Ventricular End-Systolic Volume and Volume-Derived Ejection Fraction With Outcome in Asymptomatic Chronic Aortic Regurgitation. JAMA Cardiol 2021; 6:189-198. [PMID: 33146680 DOI: 10.1001/jamacardio.2020.5268] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Volumetric measurements by transthoracic echocardiogram may better reflect left ventricular (LV) remodeling than conventional linear LV dimensions. However, the association of LV volumes with mortality in patients with chronic hemodynamically significant aortic regurgitation (AR) is unknown. Objective To assess whether LV volumes and volume-derived LV ejection fraction (Vol-LVEF) are determinants of mortality in AR. Design, Setting, and Participants This cohort study included consecutive asymptomatic patients with chronic moderately severe to severe AR from a tertiary referral center (January 2004 through April 2019). Exposures Clinical and echocardiographic data were analyzed retrospectively. Aortic regurgitation severity was graded by comprehensive integrated approach. De novo disk-summation method was used to derive LV volumes and Vol-LVEF. Main Outcome and Measures Associations between all-cause mortality under medical surveillance and the following LV indexes: linear LV end-systolic dimension index (LVESDi), linear LVEF, LV end-systolic volume index (LVESVi), and Vol-LVEF. Results Of 492 asymptomatic patients (mean [SD] age, 60 [17] years; 425 men [86%]), ischemic heart disease prevalence was low (41 [9%]), and 453 (92.1%) had preserved linear LVEF (≥50%) with mean (SD) LVESVi of 41 (15) mL/m2. At a median (interquartile range) of 5.4 (2.5-10.1) years, 66 patients (13.4%) died under medical surveillance; overall survival was not different than the age- and sex-matched general population (P = .55). Separate multivariate models, adjusted for age, sex, Charlson Comorbidity Index, and AR severity, demonstrated that in addition to linear LVEF and LVESDi, LVESVi and Vol-LVEF were independently associated with mortality under surveillance (all P < .046) with similar C statistics (range, 0.83-0.84). Spline curves showed that continuous risks of death started to rise for both linear LVEF and Vol-LVEF less than 60%, LVESVi more than 40 to 45 mL/m2, and LVESDi above 21 to 22 mm/m2. As dichotomized variables, patients with LVESVi more than 45 mL/m2 exhibited increased relative death risk (hazard ratio, 1.93; 95% CI, 1.10-3.38; P = .02) while LVESDi more than 20 mm/m2 did not (P = .32). LVESVi more than 45 mL/m2 showed a decreased survival trend compared with expected population survival. Conclusions and Relevance In this large asymptomatic cohort of patients with hemodynamically significant AR, LVESVi and Vol-LVEF worked equally as well as LVESDi and linear LVEF in risk discriminating patients with excess mortality. A LVESVi threshold of 45 mL/m2 or greater was significantly associated with an increased mortality risk.
Collapse
|
114
|
Vallabhajosyula S, Vallabhajosyula S, Yang LT, Rabinstein AA, Enriquez-Sarano M, Michelena HI. Frequency of intracranial aneurysms and sub-arachnoid hemorrhage is significantly lesser in bicuspid aortic valve than aortic coarctation. Int J Cardiol 2021; 330:229-231. [PMID: 33516839 DOI: 10.1016/j.ijcard.2021.01.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 11/04/2020] [Accepted: 01/04/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Bicuspid aortic valve(BAV) is common. Some studies suggest that all BAV patients require screening for intracranial aneurysm(IA) in order to prevent sub-arachnoid hemorrhage(SAH). Aortic coarctation(CoA) carries high-risk of both IA and SAH. Using a nationally-representative population, we assessed the frequency of IA and SAH in admissions with BAV-without-CoA versus admissions with CoA(with or without BAV). METHODS Between 2000 and 2016, adult admissions with a primary/secondary diagnosis of BAV and/or CoA were identified using the National Inpatient Sample. Admissions with traumatic SAH and inter-hospital transfers were excluded. Outcomes were frequency of IA and SAH, and in-hospital mortality in BAV-without-CoA versus CoA. RESULTS In this 17-year period, 254,675 admissions met inclusion criteria and 236,930(93.0%) had BAV-without-CoA. BAV-with-CoA was present in 2846(1.1%) and isolated-CoA in 14,899(5.9%), for a total of 17,745(7%) with CoA. IA was noted in 405 admissions(0.2%) overall, BAV-without-CoA versus CoA having 293(0.1%) versus 112(0.6%), p < 0.001. SAH was noted in 910 admissions(0.4%) overall, with BAV-without-CoA versus CoA having 760(0.3%) versus 150(0.9%), p < 0.001. CONCLUSIONS In this study, BAV-without-CoA admissions had 0.1%(6-times lower than CoA) and 0.3%(3-times lower that CoA) IA and SAH, respectively, which is comparable to the general population. This suggests that BAV-without-CoA patients likely do not require routine surveillance for IA.
Collapse
|
115
|
Benfari G, Essayagh B, Nistri S, Maalouf J, Rossi A, Thapa P, Michelena HI, Enriquez-Sarano M. Left Atrial Volumetric/Mechanical Coupling Index: A Novel Predictor of Outcome in Heart Failure With Reduced Ejection Fraction. CIRCULATION. CARDIOVASCULAR IMAGING 2021; 14:e011608. [PMID: 33463368 DOI: 10.1161/circimaging.120.011608] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Left atrial assessment is complex, particularly in heart failure with reduced ejection fraction due to interactions with functional mitral regurgitation (FMR). Pilot data suggest that left atrial volumetric/mechanical coupling index (LACI) may be useful, but large outcome data are lacking. METHODS We enrolled a comprehensively characterized cohort of patients in sinus rhythm with heart failure with reduced ejection fraction diagnosis at Mayo Clinic from 2007 to 2011. Routinely measured left atrial volume index and tissue-doppler-imaging a' allowed LACI calculation as (left atrial volume index)/(tissue-doppler-imaging a'). Survival was the outcome measured. RESULTS The cohort's 4196 patients (69 [58-77] years, ejection fraction 40 [31-45]%) had mild FMR in 1505 and moderate-severe FMR in 1068. LACI was overall 5.06 (3.50-8.10) and increased with each FMR grade (3.86 [2.94-5.29] without FMR, 5.38 [3.80-8.02] with mild, 5.45 [1.49-8.07] with moderate/severe FMR; P<0.0001). At diagnosis, higher LACI was independently determined by more severe FMR and by higher left ventricular mass index, lower ejection fraction, higher E/e', and lower glomerular filtration rate (all P<0.0001). During follow-up 1588 (38%) patients died. In spline modeling, excess mortality appeared around LACI=6 and steeply increased thereafter (5-year survival 72±1% with LACI<6 and 49±2% with LACI ≥6, P<0.0001). Multivariable comprehensive adjustment showed LACI strong association with excess mortality (adjusted hazard ratio, 1.41 [1.23-1.61], P<0.0001 for LACI ≥6). Independent link to mortality persistent across FMR grades (adjusted hazard ratio, 1.45 [1.13-1.86], P=0.004 without FMR, 1.42 [1.16-1.77], P=0.0008 with mild FMR, and 1.38 [1.01-1.66], P=0.04 with moderate/severe FMR) without interaction (P=0.3). LACI independent impact on outcome was incremental to that of left atrial volume index, tissue-doppler-imaging a', or any other characteristic including the Meta-Analysis Global Group in Chronic-score (least significant P=0.02). CONCLUSIONS In this large cohort, left atrial volumetric/mechanical coupling measured by LACI in routine practice integrates the influence of several morphological/hemodynamic determinants but displays progressive deterioration with increasing FMR severity in heart failure with reduced ejection fraction. About outcome, higher LACI is strongly, independently, and incrementally associated with excess mortality, irrespective of FMR grade and in all subsets. Hence, LACI is a novel and critical measure in heart failure with reduced ejection fraction, quantifiable in routine practice, which should be integrated in prognostication and decision-making.
Collapse
|
116
|
Fukui M, Garcia S, Lesser JR, Gössl M, Tang L, Caye D, Newell M, Hashimoto G, Lopes BBC, Stanberry LI, Enriquez-Sarano M, Pibarot P, Hahn R, Sorajja P, Cavalcante JL. Prosthesis-patient mismatch defined by cardiac computed tomography versus echocardiography after transcatheter aortic valve replacement. J Cardiovasc Comput Tomogr 2021; 15:403-411. [PMID: 33518457 DOI: 10.1016/j.jcct.2021.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 12/28/2020] [Accepted: 01/12/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUNDS Evaluation of prosthesis-patient mismatch (P-PM) after transcatheter aortic valve replacement (TAVR) by transthoracic echocardiography (TTE) has provided conflicting results regarding its impact on outcomes. Whether post-TAVR computed tomography angiography (CTA) evaluation of P-PM can improve our understanding is unknown. We aimed to evaluate the inter-modality (TTE vs. CTA) agreement, inter-valve platform (balloon-expanding valve [BEV] vs. self-expandable valve [SEV]) differences in P-PM severity, and outcomes related to P-PM after TAVR. METHODS We analyzed patients with both CTA and TTE before and after TAVR. Indexed effective orifice area was calculated using two methods: TTE-derived left ventricular outflow tract (LVOT) area from measured diameter and post-TAVR CTA-measured area. Body size specific cut-offs for P-PM severity were used: for body mass index (BMI) < 30 kg/m2, moderate = 0.66-0.85 cm2/m2 and severe≤0.65 cm2/m2; for BMI ≥30 kg/m2, moderate = 0.56-0.70 cm2/m2 and severe≤0.55 cm2/m2. RESULTS A total of 447 patients were included (median age, 83 years; 54% male). The prevalence of P-PM (moderate or severe) was lower with CTA vs. TTE (3.5% vs. 19.5%, p < 0.001). The prevalence of P-PM measured by TTE was more common in BEV compared to SEV (p = 0.002), while CTA assessment showed no difference in P-PM incidence and severity between TAVR platforms (p = 0.40). In multivariable analysis, CTA-defined but not TTE-defined P-PM was associated with mortality after TAVR (HR:3.97; 95%CI,1.55-10.2; p = 0.004). Both CTA-defined and TTE-defined P-PM were associated with the composite of death and heart failure rehospitalization. CONCLUSION Although post-TAVR CTA substantially downgraded the prevalence of P-PM compared to TTE, it identified a subset of patients with clinically relevant P-PM which associated with outcomes.
Collapse
|
117
|
Messika-Zeitoun D, Candolfi P, Dreyfus J, Burwash IG, Iung B, Philippon JF, Toussaint JM, Verta P, Feldman TE, Obadia JF, Vahanian A, Mesana T, Enriquez-Sarano M. Management and Outcome of Patients Admitted With Tricuspid Regurgitation in France. Can J Cardiol 2020; 37:1078-1085. [PMID: 33358751 DOI: 10.1016/j.cjca.2020.12.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Growing evidence shows a major outcome impact and undertreatment of tricuspid regurgitation (TR), but large and comprehensive contemporary reports of management and outcome at the nationwide level are lacking. METHODS We gathered all consecutive patients admitted with a diagnosis of likely functional TR in 2014-2015 in France from the Programme de Médicalisation des Systèmes d'Information national database and collected rate of surgery, in-hospital mortality, 1-year mortality, or heart failure (HF) readmission rates. RESULTS In 2014-2015, 17,676 consecutive patients (75 ± 14 years of age, 51% female) were admitted with a TR diagnosis. Charlson index was ≥ 2 in 56% of the population and 46% presented with HF. TR was associated with prior cardiac surgery, ischemic/dilated cardiomyopathy, or mitral regurgitation in 73% of patients. Only 10% of TR patients overall and 67% of those undergoing mitral valve surgery received a tricuspid valve intervention. Among the 13,654 (77%) conservatively managed patients, in-hospital mortality, 1-year mortality, and 1-year mortality or HF readmission rates were 5.1%, 17.8%, and 41%, respectively, overall, and 5.3%,17.2%, and 37%, respectively, among those with no underlying medical conditions (8-fold higher than predicted for age and gender). CONCLUSIONS This nationwide cohort of patients admitted with TR included elderly patients with frequent comorbidities/underlying cardiac diseases. In patients conservatively managed, mortality and morbidity were considerably high over a short time span. Despite this poor prognosis, only 10% of patients underwent a tricuspid valve intervention. These nationwide data showing a considerable risk and potential underuse of treatment highlight the critical need to develop strategies to improve the management and outcomes of TR patients.
Collapse
|
118
|
Messika-Zeitoun D, Candolfi P, Enriquez-Sarano M, Burwash IG, Chan V, Philippon JF, Toussaint JM, Verta P, Feldman TE, Iung B, Glineur D, Obadia JF, Vahanian A, Mesana T. Presentation and outcomes of mitral valve surgery in France in the recent era: a nationwide perspective. Open Heart 2020; 7:openhrt-2020-001339. [PMID: 32788294 PMCID: PMC7422639 DOI: 10.1136/openhrt-2020-001339] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/08/2020] [Accepted: 07/08/2020] [Indexed: 11/05/2022] Open
Abstract
Objectives Unbiased information regarding the surgical management of patients with mitral regurgitation (MR) at the nationwide level are scarce and mainly US-based. The Programme de Médicalisation des Systèmes d’Information, a mandatory national database, offers the unique opportunity to assess the presentation and outcomes of all consecutive mitral valve (MV) surgeries performed in France in the contemporary era. Methods We collected all MV surgeries performed for MR in France in 2014–2016. MR aetiology was classified as degenerative (DMR), secondary (SMR) or Other (rheumatic or congenital disease and infective endocarditis). Results During the 3-year period, 18 167 MV surgeries were performed in France (55% repair and 45% replacement; 52% isolated). Age was 66±12 years and 59% were male. Aetiology was DMR in 42%, SMR in 16% and other in 42% including 19% with uncertain aetiologies. Overall, in-hospital mortality was 6.5% and increased with age, female gender, Charlson Comorbidity Index, type of surgery (replacement vs repair), associated surgery (combined vs isolated) and MR aetiology (all p<0.01). In-hospital mortality and rate of death/readmission for heart failure (HF) at 1 year were 3.4% and 13%, respectively for DMR (2.4% and 11% for isolated DMR) and 7.8% and 27%, respectively for SMR (5.5% and 23% for isolated SMR). Repair rate was 55% overall, 68% in DMR and 72% for isolated DMR surgery (70% of all DMR). Repair rates decreased with age, Charlson Comorbidity Index and female sex (all p<0.0001). Conclusion In this cross-sectional contemporary prospective nationwide database, in-hospital mortality and 1 year rate of death and HF readmission were considerable overall and in all subsets. Repair rates were suboptimal overall especially in the elderly and women subsets. These results underline the need to develop strategies to improve management and outcomes of patients with both DMR and SMR.
Collapse
|
119
|
Essayagh B, Sabbag A, Benfari G, Enriquez-Sarano M. Reply: The Arrhythmic Mitral Valve Prolapse: The Questions and the Way Forward. J Am Coll Cardiol 2020; 76:2691-2693. [PMID: 33243391 DOI: 10.1016/j.jacc.2020.09.589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 09/27/2020] [Indexed: 11/26/2022]
|
120
|
Enriquez-Sarano M, Gössl M, Prendergast B, Michelena H. Valvular Heart Diseases Surveillance: A Commanding Necessity. Mayo Clin Proc 2020; 95:2585-2588. [PMID: 33276829 DOI: 10.1016/j.mayocp.2020.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/20/2020] [Indexed: 11/29/2022]
|
121
|
Yang LT, Daniels BK, Enriquez-Sarano M, Michelena HI. Reply. J Am Coll Cardiol 2020; 76:2177-2179. [DOI: 10.1016/j.jacc.2020.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/01/2020] [Indexed: 11/26/2022]
|
122
|
Yang L, Benfari G, Nkomo V, Enriquez-Sarano M, Pellikka P, Michelena H. Aortic regurgitation is not created equal: outcomes of bicuspid versus tricuspid aortic valve regurgitation. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Bicuspid aortic valve (BAV) is an important cause of AR; these patients belong to a young and male predominant population and are distinctively different from tricuspid aortic valve (TAV). However, the differences between BAV and TAV in AR have not been completely explored.
Purpose
To explore differences between patients with BAV and TAV in hemodynamically significant aortic regurgitation (AR).
Methods
Consecutive patients with ≥moderate-severe AR were retrospectively identified from 2006 to 2017.
Results
Of 798 patients (502 with TAV, mean age 67±14 years; 296 with BAV, mean age 46±14 years) followed for 6.1±3.6 years, 403 underwent AV surgery (AVS); 154 died during follow-up.
BAV men (94%) tended to become symptomatic when left ventricle enlarged; TAV patients became symptomatic before left ventricular (LV) enlargement. During follow-up, BAV patients had lower mortality (hazard ratio [HR], 0.19; P<0.0001) and higher incidence of AVS (HR, 1.28; P=0.01) than TAV, which attenuated after adjusted on age, sex, comorbidities, LV ejection fraction (LVEF), functional class, and time-dependent AVS. In a propensity-matched cohort, differences of survival and incidence of AVS between BAV and TAV were not demonstrated. After a median of 6.3 (IQR: 3.3–9.3) years, 53 patients died post-AVS; TAV patients having class I surgical triggers had poor survival than TAV-non-class I patients and BAV patients with and without class I triggers (Figure). Class I triggers had no effect on BAV patients regarding post-AVS survival. LVEF<60% was associated with increased mortality in both TAV and BAV.
Conclusions
The correlation between larger LV size and symptomatic status only applied in BAV men. Patients with BAV and significant AR tended to have better survival and higher incidence of AVS, likely driven by inherent younger age and less comorbidity than patients with TAV. Class I surgical triggers had heavier negative impact on poor survival in TAV patients. The cutoff of LV dysfunction in AR may be LVEF 60%.
Figure 1. Kaplan-Meier curves post-AVS
Funding Acknowledgement
Type of funding source: None
Collapse
|
123
|
Dziadzko V, Dziadzko M, Medina-Inojosa JR, Benfari G, Michelena HI, Crestanello JA, Maalouf J, Thapa P, Enriquez-Sarano M. Causes and mechanisms of isolated mitral regurgitation in the community: clinical context and outcome. Eur Heart J 2020; 40:2194-2202. [PMID: 31121021 DOI: 10.1093/eurheartj/ehz314] [Citation(s) in RCA: 138] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 02/15/2019] [Accepted: 05/06/2019] [Indexed: 11/13/2022] Open
Abstract
AIMS To define the hitherto unknown aetiology/mechanism distributions of mitral regurgitation (MR) in the community and the linked clinical characteristics/outcomes. METHODS AND RESULTS We identified all isolated, moderate/severe MR diagnosed in our community (Olmsted County, MN, USA) between 2000 and 2010 and classified MR aetiology/mechanisms. Eligible patients (n = 727) were 73 ± 18 years, 51% females, with ejection fraction (EF) 49 ± 17%. MR was functional (FMR) in 65%, organic (OMR) in 32% and 2% mixed. Functional MR was linked to left ventricular remodelling (FMR-v) 38% and isolated atrial dilatation (FMR-a) 27%. At diagnosis FMR-v vs. FMR-a, vs. OMR displayed profound differences (all P < 0.0001) in age (73 ± 14, 80 ± 10, 68 ± 21years), male-sex (59, 33, 51%), atrial-fibrillation (28, 54, 13%), EF (33 ± 14, 57 ± 11, 61 ± 10%), and regurgitant-volume (38 ± 13, 37 ± 11, 51 ± 24 mL/beat). Dominant MR mechanism was Type I (normal valve-movement) 38%, Type II (excessive valve-movement) 25%, Type IIIa (diastolic movement-restriction) 3%, and Type IIIb (systolic movement-restriction) 34%. Outcomes were mediocre with excess-mortality vs. general-population in FMR-v [risk ratio 3.45 (2.98-3.99), P < 0.0001] but also FMR-a [risk ratio 1.88 (1.52-2.25), P < 0.0001] and OMR [risk ratio 1.83 (1.50-2.22), P < 0.0001]. Heart failure was frequent, particularly in FMR-v (5-year 83 ± 3% vs. 59 ± 4% FMR-a, 40 ± 3% OMR, P < 0.0001). Mitral surgery during patients' lifetime was performed in 4% of FMR-v, 3% of FMR-a, and 37% of OMR. CONCLUSION Moderate/severe isolated MR in the community displays considerable aetiology/mechanism heterogeneity. Functional MR dominates, mostly FMR-v but FMR-a is frequent and degenerative MR dominates OMR. Outcomes are mediocre with excess-mortality particularly with FMR-v but FMR-a, despite normal EF incurs notable excess-mortality and frequent heart failure. Pervasive undertreatment warrants clinical trials of therapies tailored to specific MR cause/mechanisms.
Collapse
|
124
|
Yang LT, Benfari G, Eleid M, Scott CG, Nkomo VT, Pellikka PA, Anavekar NS, Enriquez-Sarano M, Michelena HI. Contemporary differences between bicuspid and tricuspid aortic valve in chronic aortic regurgitation. Heart 2020; 107:916-924. [PMID: 33109713 DOI: 10.1136/heartjnl-2020-317466] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 09/15/2020] [Accepted: 09/19/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To comprehensively explore contemporary differences between bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) patients with chronic haemodynamically significant aortic regurgitation (AR). METHODS Consecutive patients with chronic ≥moderate-severe AR from a tertiary referral centre (2006-2017) were included. All-cause mortality, surgical indications and aortic valve surgery (AVS) were analysed. RESULTS Of 798 patients (296 BAV-AR, age 46±14 years; 502 TAV-AR, age 67±14 years, p<0.0001) followed for 5.5 (IQR: 2.9-9.2) years, 403 underwent AVS (repair in 96) and 154 died during follow-up. The 8-year AVS incidence was 60%±3% versus 53%±3% for BAV-AR and TAV-AR, respectively (p=0.014). The unadjusted (real-life) 8-year total survival was 93%±7% versus 71%±2% for BAV-AR and TAV-AR, respectively (p<0.0001), and became statistically insignificant after sole adjustment for age (p=0.14). The within-group relative risk of death in BAV-AR patients demonstrated a large age-dependent increase (two fold at 50-55 years, up to 10-fold at 70 years). The presence of baseline symptoms was significantly associated with death for both BAV-AR (p=0.039) and TAV-AR (p<0.0001), but the strength of the association decreased with age adjustment for BAV-AR (age-adjusted HR 2.43 (0.92-6.39), p=0.07) and not for TAV-AR (age-adjusted HR, 2.3 (1.6-3.3), p<0.0001). As compared with general population, TAV-AR exhibited baseline excess risk which further increased at left ventricular ejection fraction (LVEF) <60% and left ventricular end-systolic dimension index (LVESDi) >20 mm/m2; similar thresholds were observed for BAV-AR patients. CONCLUSION BAV-AR patients were two decades younger than TAV-AR and underwent AVS more frequently, resulting in a considerable real-life survival advantage for BAV-AR that was determined primarily by age and not valve anatomy. Pragmatically, regardless of valve anatomy, patients with haemodynamically significant AR and age >50-55 years require a low-threshold for surgical referral to prevent symptom development where LVEF <60% and LVESDi >20 mm/m2 seem appropriate referral thresholds.
Collapse
|
125
|
Jenkins WS, Simard L, Clavel MA, Foley TA, Araoz PA, Miller JD, Thaden J, Messika-Zeitoun D, Enriquez-Sarano M. Pathophysiology of Aortic Valve Calcification and Stenosis. JACC Cardiovasc Imaging 2020; 13:2255-2258. [DOI: 10.1016/j.jcmg.2020.04.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 04/23/2020] [Accepted: 04/24/2020] [Indexed: 12/01/2022]
|