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Acute Decompensated Aortic Stenosis: State of the Art Review. Curr Probl Cardiol 2022; 48:101422. [PMID: 36167225 DOI: 10.1016/j.cpcardiol.2022.101422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 09/21/2022] [Indexed: 11/21/2022]
Abstract
Aortic stenosis (AS) is a progressive disease that carries a poor prognosis. Patients are managed conservatively until satisfying an indication for transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) based on AS severity and the presence of symptoms or adverse impact on the myocardium. Up to 1 in 3 TAVIs are performed for patients with acute symptoms of dyspnoea at rest, angina, and/or syncope - termed acute decompensated aortic stenosis (ADAS) and require urgent aortic valve replacement. These patients have longer hospital length of stay, undergo physical deconditioning, have a higher rate of acute kidney injury and mortality compared to stable patients with less severe symptoms. There is an urgent need to prevent ADAS and to deliver pathways to manage and improve ADAS-related outcomes. We provide here a contemporary review on epidemiological and pathophysiological aspects of ADAS, with a focus on the impact of ADAS from clinical and economic perspectives. We will offer also a global overview of the available evidence for treatment of ADAS and with priorities suggested for addressing current gaps in the literature and unmet clinical needs to improve outcomes for AS patients.
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Palacios-Fernandez S, Salcedo M, Belinchon-Romero I, Gonzalez-Alcaide G, Ramos-Rincón JM. Epidemiological and Clinical Features in Very Old Men and Women (≥80 Years) Hospitalized with Aortic Stenosis in Spain, 2016-2019: Results from the Spanish Hospital Discharge Database. J Clin Med 2022; 11:jcm11195588. [PMID: 36233458 PMCID: PMC9571913 DOI: 10.3390/jcm11195588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/29/2022] [Accepted: 09/20/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Background: The aging population poses challenges for hospital systems. Aortic stenosis is among the most frequent diseases in very old patients. The aim of this study was to describe gender and age differences in the clinical characteristics of very old patients hospitalized with aortic stenosis (AoS) in Spain from 2016 to 2019. (2): Methods: A retrospective observational study analyzing data from the national surveillance system for hospital data. Variables analyzed were age group, sex, length of stay, deaths, and comorbidity. (3) Results: The analysis included 46,967 discharges. Altogether, 7.6% of the admissions ended in death. The main reason for admission was heart failure (34.3%), and this increased with age (80−84 years: 26% versus 95−99 years: 56.6%; p < 0.001). The main treatment procedure was the transcatheter aortic valve replacement (12.7%), performed in 14.3% of patients aged 80−84 versus 0.5% in patients aged 95−99 (p < 0.001). In the multivariable analysis, women were admitted with more comorbidities (odds ratio [OR] 1.22, 95% confidence interval [CI] 1.06−1.20). Mortality was similar, albeit women were admitted less for syncope (OR 0.83, 95% CI 0.74−0.93). Women also underwent fewer coronary catheterizations (OR 0.81, 95% CI 0.77−0.87) and echocardiograms (OR 0.96, 95% CI 0.94−0.98). (4) Conclusions: Aortic stenosis leads to a high number of hospital admissions. Women with AoS presented more heart failure and less cardiovascular pathology than men. Also, women are admitted with fewer episodes of syncope and have fewer ultrasounds and catheterizations.
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Affiliation(s)
| | - Mario Salcedo
- Department of Internal Medicine, San Pedro Hospital, 26006 Logroño, Spain
| | | | | | - José-Manuel Ramos-Rincón
- Department of Clinical Medicine, Miguel Hernandez University, 03550 Alicante, Spain
- Department of Internal Medicine, Alicante General University Hospital-Alicante Institute for Health and Biomedical Research (ISABIAL), 03010 Alicante, Spain
- Correspondence:
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Patel KP, Badiani S, Ganeshalingam A, Vijayakumar M, Thornton G, Mathur A, Kennon S, Bhattacharyya S, Baumbach A, Moon JC, Treibel TA, Mullen MJ, Lloyd G. Preprocedural Prognostic Factors in Acute Decompensated Aortic Stenosis. Am J Cardiol 2022; 174:96-100. [PMID: 35527043 DOI: 10.1016/j.amjcard.2022.03.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/26/2022] [Accepted: 03/02/2022] [Indexed: 12/18/2022]
Abstract
Acute decompensated aortic stenosis (ADAS) is common and associated with poor outcomes. Myocardial remodeling and function, including a novel echo staging classification (0 to 4, representing increasing degrees of cardiac damage/dysfunction), impact outcomes in stable aortic stenosis. However, this has not been assessed in patients with ADAS. This study aims to evaluate the impact of the myocardium, echo staging classification, and clinical parameters on mortality in ADAS. ADAS was defined as an acute deterioration in symptoms (New York Heart Association 4, Canadian Cardiovascular Society 3/4, or syncope) that warranted admission to the hospital and urgent aortic valve replacement. Using a retrospective observational study design, 292 consecutive patients with ADAS who underwent transcatheter aortic valve implantation (TAVI) were identified and included in this study. Echocardiographic and clinical characteristics were evaluated using regression analysis. The outcome was all-cause mortality after TAVI. At 1 year after TAVI, advanced echo staging (>2) independently predicted mortality (hazards ratio: 1.85, 95% confidence interval: 1.01 to 3.39; p = 0.045). At a follow-up of 2.4 ± 1.4 years, myocardial, valvular, and clinical parameters did not predict mortality, except for frailty (hazards ratio: 2.31, 95% confidence interval: 1.38 to 3.85; p = 0.001). In patients with ADAS, short-term mortality after TAVI is influenced by more advanced cardiac damage/dysfunction based on the echo staging classification, whereas mid-term mortality is driven by frailty rather than echo staging classification.
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Affiliation(s)
- Kush P Patel
- Barts Heart Centre, St Bartholomew's Hospital, London; Institute of Cardiovascular Science, University College London, London
| | | | | | - Mohit Vijayakumar
- Institute of Cardiovascular Science, University College London, London
| | - George Thornton
- Barts Heart Centre, St Bartholomew's Hospital, London; Institute of Cardiovascular Science, University College London, London
| | - Anthony Mathur
- Barts Heart Centre, St Bartholomew's Hospital, London; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London; Yale University School of Medicine, New Haven, Connecticut
| | - Simon Kennon
- Barts Heart Centre, St Bartholomew's Hospital, London
| | | | - Andreas Baumbach
- Barts Heart Centre, St Bartholomew's Hospital, London; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London; Yale University School of Medicine, New Haven, Connecticut
| | - James C Moon
- Barts Heart Centre, St Bartholomew's Hospital, London; Institute of Cardiovascular Science, University College London, London
| | - Thomas A Treibel
- Barts Heart Centre, St Bartholomew's Hospital, London; Institute of Cardiovascular Science, University College London, London
| | - Michael J Mullen
- Barts Heart Centre, St Bartholomew's Hospital, London; Institute of Cardiovascular Science, University College London, London
| | - Guy Lloyd
- Barts Heart Centre, St Bartholomew's Hospital, London; Institute of Cardiovascular Science, University College London, London; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London.
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Novel Echocardiography-Derived Left Ventricular Stiffness Index in Low-Flow Versus Normal-Flow Severe Aortic Stenosis with Preserved Left Ventricular Ejection Fraction. Sci Rep 2020; 10:9086. [PMID: 32493908 PMCID: PMC7270100 DOI: 10.1038/s41598-020-65758-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 05/06/2020] [Indexed: 11/08/2022] Open
Abstract
Background Paradoxical low-flow (LF) severe aortic stenosis (AS) with preserved left ventricular ejection fraction (LVEF) may have poorer prognosis than normal-flow (NF) AS, though its pathophysiology remained unclear. In particular, LV stiffness has not been compared between LF vs NF. We used a novel echocardiography-derived index of LV stiffness to compare between these groups. Consecutive patients with medically-managed isolated severe AS (aortic valve area < 1 cm2) and preserved LVEF (>50%) were studied. Echocardiographic LV stiffness index was measured by a method previously validated against cardiac catheterization. We compared LF (stroke volume index, SVI < 35 ml/m2) and NF severe AS. Of the 352 patients, 121 (34%) were LF. Both LF and NF groups had similar demographics, valve areas and indices. Compared to NF, LF severe AS had higher LV stiffness indices (>0.11 ml-1 OR 3.067, 95% CI 1.825-5.128, p < 0.001). Increased LV stiffness was associated with concentric remodelling and more severe diastolic dysfunction, especially in LF AS. An LV stiffness index of > 0.11 ml-1 was independently associated with increased mortality, after adjusting for age, clinical and echocardiographic parameters (HR 2.283 95% CI 1.318-3.968, p = 0.003). Non-invasive echocardiographic-derived index of LV stiffness may be important in LF AS. Increased LV stiffness was related to LV concentric remodelling and diastolic dysfunction, and associated with poorer clinical outcomes in medically-managed AS.
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Tastet L, Kwiecinski J, Pibarot P, Capoulade R, Everett RJ, Newby DE, Shen M, Guzzetti E, Arsenault M, Bédard É, Larose É, Beaudoin J, Dweck M, Clavel MA. Sex-Related Differences in the Extent of Myocardial Fibrosis in Patients With Aortic Valve Stenosis. JACC Cardiovasc Imaging 2020; 13:699-711. [PMID: 31422128 DOI: 10.1016/j.jcmg.2019.06.014] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 06/13/2019] [Accepted: 06/14/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aim of this study was to assess the effect of sex on myocardial fibrosis as assessed by using cardiac magnetic resonance (CMR) imaging in aortic stenosis (AS). BACKGROUND Previous studies reported sex-related differences in the left ventricular (LV) remodeling response to pressure overload in AS. However, there are very few data regarding the effect of sex on myocardial fibrosis, a key marker of LV decompensation and adverse cardiac events in AS. METHODS A total of 249 patients (mean age 66 ± 13 years; 30% women) with at least mild AS were recruited from 2 prospective observational cohort studies and underwent comprehensive Doppler echocardiography and CMR examinations. On CMR, T1 mapping was used to quantify extracellular volume (ECV) fraction as a marker of diffuse fibrosis, and late gadolinium enhancement (LGE) was used to assess focal fibrosis. RESULTS There was no difference in age between women and men (age 66 ± 15 years vs 66 ± 12 years; p = 0.78). However, women presented with a better cardiovascular risk profile than men with less hypertension, dyslipidemia, diabetes, and coronary artery disease (all, p ≤ 0.10). As expected, LV mass index measured by CMR imaging was smaller in women than in men (p < 0.0001). Despite fewer comorbidities, women presented with larger ECV fraction (median: 29.0% [25th to 75th percentiles: 27.4% to 30.6%] vs. 26.8% [25th to 75th percentiles: 25.1% to 28.7%]; p < 0.0001) and similar LGE (median: 4.5% [25th-75th percentiles: 2.3% to 7.0%] vs. 2.8% [25th-75th percentiles: 0.6% to 6.8%]; p = 0.20) than men. In multivariable analysis, female sex remained an independent determinant of higher ECV fraction and LGE (all, p ≤ 0.05). CONCLUSIONS Women have greater diffuse and focal myocardial fibrosis independent of the degree of AS severity. These findings further emphasize the sex-related differences in LV remodeling response to pressure overload.
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Affiliation(s)
- Lionel Tastet
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Jacek Kwiecinski
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Romain Capoulade
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Russell J Everett
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Mylène Shen
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Ezequiel Guzzetti
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Marie Arsenault
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Élisabeth Bédard
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Éric Larose
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Jonathan Beaudoin
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Marc Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada.
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Aortic Stenosis Is Still Very Tricky, Especially When it Is Moderate. J Am Coll Cardiol 2017; 69:2393-2396. [PMID: 28494977 DOI: 10.1016/j.jacc.2017.03.569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 03/27/2017] [Indexed: 12/21/2022]
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Kamimura D, Suzuki T, Fox ER, Skelton TN, Winniford MD, Hall ME. Increased Left Ventricular Diastolic Stiffness Is Associated With Heart Failure Symptoms in Aortic Stenosis Patients With Preserved Ejection Fraction. J Card Fail 2017; 23:581-588. [PMID: 28495455 DOI: 10.1016/j.cardfail.2017.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 04/16/2017] [Accepted: 05/05/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Clinical risk factors associated with heart failure (HF) symptoms in aortic stenosis (AS) patients with preserved ejection fraction (EF) have not been fully identified. We hypothesized that left ventricular (LV) diastolic stiffness is associated with HF symptoms in patients with AS. METHODS AND RESULTS We retrospectively evaluated 275 patients with at least moderate AS (aortic valve area <1.5 cm2) and preserved EF (≥50%). LV diastolic stiffness was evaluated with the use of echocardiographic parameters, diastolic wall strain (DWS, a measure of LV wall stiffness), and KLV (a marker of LV chamber stiffness). There were 69 patients with HF. Patients with HF were older, were more likely to be African American, had a higher body mass index, and had more hypertension and coronary artery disease (P < .05 for all). Aortic valve area index and mean pressure gradient across the aortic valve were not different between patients with and without HF. Despite similar echocardiographic parameters of AS severity, patients with HF had stiffer LV (DWS 0.21 ± 0.06 vs 0.25 ± 0.06 [P < .01], KLV 0.17 ± 0.11 vs 0.13 ± 0.08 [P < .01]). Logistic regression analyses revealed that after adjusting for age, race, body mass index, history of hypertension, and coronary artery disease, LV diastolic stiffness parameters remained significantly associated with HF symptoms. CONCLUSIONS LV diastolic stiffness is independently associated with HF in AS patients with preserved EF.
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Affiliation(s)
- Daisuke Kamimura
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi.
| | - Takeki Suzuki
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Ervin R Fox
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Thomas N Skelton
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Michael D Winniford
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Michael E Hall
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
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Affiliation(s)
- Dennis A. Tighe
- From the Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Gerard P. Aurigemma
- From the Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester
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Orwat S, Kaleschke G, Kerckhoff G, Radke R, Baumgartner H. Low flow, low gradient severe aortic stenosis: diagnosis, treatment and prognosis. EUROINTERVENTION 2013; 9 Suppl:S38-42. [DOI: 10.4244/eijv9ssa8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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