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Anastasiou V, Daios S, Karamitsos T, Peteinidou E, Didagelos M, Giannakoulas G, Aggeli C, Tsioufis K, Ziakas A, Kamperidis V. Multimodality imaging for the global evaluation of aortic stenosis: The valve, the ventricle, the afterload. Trends Cardiovasc Med 2024:S1050-1738(24)00015-X. [PMID: 38387745 DOI: 10.1016/j.tcm.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 02/03/2024] [Accepted: 02/04/2024] [Indexed: 02/24/2024]
Abstract
Aortic stenosis (AS) is the most common valvular heart disease growing in parallel to the increment of life expectancy. Besides the valve, the degenerative process affects the aorta, impairing its elastic properties and leading to increased systemic resistance. The composite of valvular and systemic afterload mediates ventricular damage. The first step of a thorough evaluation of AS should include a detailed assessment of valvular anatomy and hemodynamics. Subsequently, the ventricle, and the global afterload should be assessed to define disease stage and prognosis. Multimodality imaging is of paramount importance for the comprehensive evaluation of these three elements. Echocardiography is the cornerstone modality whereas Multi-Detector Computed Tomography and Cardiac Magnetic Resonance provide useful complementary information. This review comprehensively examines the merits of these imaging modalities in AS for the evaluation of the valve, the ventricle, and the afterload and ultimately endeavors to integrate them in a holistic assessment of AS.
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Affiliation(s)
- Vasileios Anastasiou
- 1st Department of Cardiology, AHEPA Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stylianos Daios
- 1st Department of Cardiology, AHEPA Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodoros Karamitsos
- 1st Department of Cardiology, AHEPA Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Emmanouela Peteinidou
- 1st Department of Cardiology, AHEPA Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Matthaios Didagelos
- 1st Department of Cardiology, AHEPA Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Giannakoulas
- 1st Department of Cardiology, AHEPA Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Constantina Aggeli
- 1st Department of Cardiology, Hippokration Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Tsioufis
- 1st Department of Cardiology, Hippokration Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonios Ziakas
- 1st Department of Cardiology, AHEPA Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasileios Kamperidis
- 1st Department of Cardiology, AHEPA Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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Yagi N, Ogawa M, Kuwajima K, Hasegawa H, Yamane T, Shiota T. Impact of stroke volume assessment by three-dimensional transesophageal echocardiography on the classification of low-gradient aortic stenosis. J Echocardiogr 2024:10.1007/s12574-023-00638-4. [PMID: 38300382 DOI: 10.1007/s12574-023-00638-4] [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: 06/27/2023] [Revised: 09/12/2023] [Accepted: 12/20/2023] [Indexed: 02/02/2024]
Abstract
BACKGROUND Accurate assessment of flow status is crucial in low-gradient aortic stenosis (AS). However, the clinical implication of three-dimensional transesophageal echocardiography (3DTEE) on flow status evaluation remains unclear. This study aimed to investigate the assessment of flow status using 3D TEE in low-gradient AS patients. METHODS We retrospectively reviewed patients diagnosed with low-gradient AS and preserved ejection fraction at our institution between 2019 and 2022. Patients were categorized into low-flow/low-gradient (LF-LG) AS or normal-flow/low-gradient (NF-LG) AS based on two-dimensional transthoracic echocardiography (2DTTE). We compared the left ventricular outflow tract (LVOT) geometry between the two groups and reclassified them using stroke volume index (SVi) obtained by 3DTEE. RESULTS Among 173 patients (105 with LF-LG AS and 68 with NF-LG AS), 54 propensity-matched pairs of patients were analyzed. 3DTEE-derived ellipticity index of LVOT was significantly higher in LF-LG AS patients compared to NF-LG AS patients (p = 0.012). We assessed the discordance in flow status classification between SVi2DTTE and SVi3DTEE in both groups using a cutoff value of 35 ml/m2. The LF-LG AS group exhibited a significantly higher discordance rate compared to the NF-LG AS group, with rates of 50% and 2%, respectively. The optimal cutoff values of SVi3DTEE for identifying low flow status, based on 2DTTE-derived cutoff values, were determined to be 43 ml/m2. CONCLUSIONS LVOT ellipticity in low-gradient AS patients varies depending on flow status, and this difference contributes to discrepancies between SVi3DTEE and SVi2DTTE, particularly in LF-LG AS patients. Utilizing SVi3DTEE is valuable for accurately assessing flow status.
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Affiliation(s)
- Nobuichiro Yagi
- Cedars-Sinai Medical Center, Smidt Heart Institute, Beverly Blvd, Los Angeles, CA, 8700, USA.
| | - Mana Ogawa
- Cedars-Sinai Medical Center, Smidt Heart Institute, Beverly Blvd, Los Angeles, CA, 8700, USA
| | - Ken Kuwajima
- Cedars-Sinai Medical Center, Smidt Heart Institute, Beverly Blvd, Los Angeles, CA, 8700, USA
| | - Hiroko Hasegawa
- Cedars-Sinai Medical Center, Smidt Heart Institute, Beverly Blvd, Los Angeles, CA, 8700, USA
| | - Takafumi Yamane
- Cedars-Sinai Medical Center, Smidt Heart Institute, Beverly Blvd, Los Angeles, CA, 8700, USA
| | - Takahiro Shiota
- Cedars-Sinai Medical Center, Smidt Heart Institute, Beverly Blvd, Los Angeles, CA, 8700, USA
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Santos-Ferreira D, Fernandes I, Diaz SO, Guerreiro C, Saraiva F, Barros AS, Leite-Moreira A, Pereira E, Sampaio F, Ribeiro J, Braga P, Fontes-Carvalho R. Prognostic value of flow-status in severe aortic stenosis patients undergoing percutaneous intervention. Int J Cardiovasc Imaging 2024; 40:341-350. [PMID: 37981631 PMCID: PMC10884040 DOI: 10.1007/s10554-023-02992-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 10/21/2023] [Indexed: 11/21/2023]
Abstract
PURPOSE Low-flow status is a mortality predictor in severe aortic stenosis (SAS) patients, including after transcatheter aortic valve implantation (TAVI) treatment. However, the best parameter to assess flow is unknown. Recent studies suggest that transaortic flow rate (FR) is superior to currently used stroke volume index (SVi) in defining low-flow states. Therefore, we aimed to evaluate the prognostic value of FR and SVi in patients undergoing TAVI. METHODS A single-centre retrospective analysis of all consecutive patients treated with TAVI for SAS between 2011 and 2019 was conducted. Low-FR was defined as < 200 mL/s and low-SVi as < 35 mL/m2. Primary endpoint was all-cause five-year mortality, analyzed using Kaplan-Meier curves and Cox regression models. Secondary endpoint was variation of NYHA functional class six months after procedure. Patients were further stratified according to ejection fraction (EF < 50%). RESULTS Of 489 cases, 59.5% were low-FR, and 43.1% low-SVi. Low-flow patients had superior surgical risk, worse renal function, and had a higher prevalence of coronary artery disease. Low-FR was associated with mortality (hazard ratio 1.36, p = 0.041), but not after adjustment to EuroSCORE II. Normal-SVi was not associated with survival, despite a significative p-trend for its continuous value. No associations were found for flow-status and NYHA recovery. When stratifying according to preserved and reduced EF, both FR and SVi did not predict all-cause mortality. CONCLUSION In patients with SAS undergoing TAVI, a low-FR state was associated with higher mortality, as well as SVi, but not at a 35 mL/m2 cut off.
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Affiliation(s)
- Diogo Santos-Ferreira
- Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Rua Conceição Fernandes, Vila Nova de Gaia, 4434-502, Portugal
- Department of Surgery and Physiology, UnIC@RISE, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, 4200-319, Portugal
| | - Isabel Fernandes
- Department of Surgery and Physiology, UnIC@RISE, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, 4200-319, Portugal
| | - Sílvia O Diaz
- Department of Surgery and Physiology, UnIC@RISE, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, 4200-319, Portugal
| | - Cláudio Guerreiro
- Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Rua Conceição Fernandes, Vila Nova de Gaia, 4434-502, Portugal
| | - Francisca Saraiva
- Department of Surgery and Physiology, UnIC@RISE, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, 4200-319, Portugal
| | - António S Barros
- Department of Surgery and Physiology, UnIC@RISE, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, 4200-319, Portugal
| | - Adelino Leite-Moreira
- Department of Surgery and Physiology, UnIC@RISE, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, 4200-319, Portugal
| | - Eulália Pereira
- Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Rua Conceição Fernandes, Vila Nova de Gaia, 4434-502, Portugal
| | - Francisco Sampaio
- Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Rua Conceição Fernandes, Vila Nova de Gaia, 4434-502, Portugal
- Department of Surgery and Physiology, UnIC@RISE, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, 4200-319, Portugal
| | - José Ribeiro
- Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Rua Conceição Fernandes, Vila Nova de Gaia, 4434-502, Portugal
| | - Pedro Braga
- Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Rua Conceição Fernandes, Vila Nova de Gaia, 4434-502, Portugal
| | - Ricardo Fontes-Carvalho
- Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Rua Conceição Fernandes, Vila Nova de Gaia, 4434-502, Portugal.
- Department of Surgery and Physiology, UnIC@RISE, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, 4200-319, Portugal.
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Al-Atta A, Farag M, Jeyalan V, Gazzal Asswad A, Thompson A, Irvine T, Edwards R, Das R, Zaman A, Alkhalil M. Low Transvalvular Flow Rate in Patients Undergoing Transcatheter Aortic Valve Implantation (TAVI) Is a Predictor of Mortality: The TFR-TAVI Study. Heart Lung Circ 2023; 32:1489-1499. [PMID: 37993343 DOI: 10.1016/j.hlc.2023.09.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 07/12/2023] [Accepted: 09/21/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Transvalvular flow rate (TFR) represents a better reflection of transvalvular flow than the stroke volume index (SVi), and has recently emerged as a useful prognostic tool in patients undergoing surgical aortic valve replacement. There is a paucity of data investigating the role of TFR and its relationship with other clinical or echocardiographic factors in patients undergoing transcatheter aortic valve implantation (TAVI). METHOD This was a retrospective single-centre study of 629 consecutive patients who underwent TAVI between March 2009 and September 2020. Pre-TAVI low TFR was defined as <200 c/s. The primary study end point was all-cause mortality. RESULTS Low TFR was observed in 41.8% (263/629) of included patients and was associated with increasing age, low body surface area, hypertension, diabetes, atrial fibrillation, left ventricular (LV) dysfunction, and significant mitral regurgitation. LV function status and severity of aortic valve disease were independent predictors of low TFR. Low TFR was significantly associated with long-term all-cause mortality even after adjustment for other risk factors (adjusted hazard ratio [aHR] 1.44; 95% confidence interval [CI] 1.02-2.03; p=0.038). When data were stratified according to SVi, low TFR was an independent predictor of long-term all-cause mortality in patients with normal SVi (aHR 1.98; 95% CI 1.06-3.69; p=0.032) but not in patients with low SVi (HR 1.23; 95% CI 0.71-2.11; p=0.46; p=0.016 for interaction). CONCLUSIONS Low TFR is common in patients undergoing TAVI and is an independent predictor of all-cause mortality, particularly in patients with normal SVi.
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Affiliation(s)
- Ayman Al-Atta
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK
| | - Mohamed Farag
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK
| | - Visvech Jeyalan
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK
| | | | | | - Tim Irvine
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK
| | - Richard Edwards
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK
| | - Rajiv Das
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK
| | - Azfar Zaman
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Mohammed Alkhalil
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.
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Pavlides GS, Chatzizisis YS, Porter TR. Integrating hemodynamics with ventricular and valvular remodeling in aortic stenosis. A paradigm shift in therapeutic decision making. Am Heart J 2022; 254:66-76. [PMID: 35970400 DOI: 10.1016/j.ahj.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 08/05/2022] [Accepted: 08/06/2022] [Indexed: 06/15/2023]
Abstract
Aortic valve stenosis (AS) has traditionally been approached in hemodynamic terms. Although hemodynamics and symptoms have formed the basis of recommending interventional treatment in AS, other factors reflecting left ventricular and valvular and/or vascular remodeling are equally important for the prognosis and outcome of patients with AS. Left ventricular and valvular/vascular remodeling in AS do not consistently correlate with hemodynamic severity of AS. Those remodeling changes are reflected and can be detected by a variety of novel laboratory and imaging techniques, including biomarkers, echocardiography, cardiac magnetic resonance and gated Computer Tomography (CT) imaging. Taking all those elements into Heart Team therapeutic decision making in patients with AS, can significantly improve appropriate patient selection for interventional treatment and patient outcomes. We review this novel approach and propose a simple algorithm for decision making by the Heart Team, in patients with moderate or severe AS.
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6
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e895-e1032. [PMID: 35363499 DOI: 10.1161/cir.0000000000001063] [Citation(s) in RCA: 612] [Impact Index Per Article: 306.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison
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7
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Definition and diagnosis of paradoxical aortic stenosis: A call for reappraisal. Arch Cardiovasc Dis 2022; 115:243-248. [DOI: 10.1016/j.acvd.2022.01.006] [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: 12/28/2021] [Revised: 01/23/2022] [Accepted: 01/24/2022] [Indexed: 11/20/2022]
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8
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2022; 79:e263-e421. [PMID: 35379503 DOI: 10.1016/j.jacc.2021.12.012] [Citation(s) in RCA: 694] [Impact Index Per Article: 347.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. STRUCTURE Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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9
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Gennari M, Mastroiacovo G, Trabattoni P, Roberto M, Bonomi A, Bartorelli AL, Olivares P, Tamborini G, Muratori M, Pepi M, Polvani G, Agrifoglio M. The prognostic value of left ventricular dimensions at the time of transcatheter aortic valve replacement: A propensity‐matched analysis. J Card Surg 2022; 37:1887-1893. [DOI: 10.1111/jocs.16381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 01/17/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Marco Gennari
- Department of Cardiovascular Surgery IRCCS Centro Cardiologico Monzino Milan Italy
| | - Giorgio Mastroiacovo
- Department of Cardiovascular Surgery IRCCS Centro Cardiologico Monzino Milan Italy
| | - Piero Trabattoni
- Department of Cardiovascular Surgery IRCCS Centro Cardiologico Monzino Milan Italy
| | - Maurizio Roberto
- Department of Cardiovascular Surgery IRCCS Centro Cardiologico Monzino Milan Italy
| | - Alice Bonomi
- Department of Statistics IRCCS Centro Cardiologico Monzino Milan Italy
| | - Antonio L. Bartorelli
- Department of Biomedical and Clinical Sciences “Luigi Sacco” University of Milan Milan Italy
| | - Paolo Olivares
- Department of Interventional Cardiology IRCCS Centro Cardiologico Monzino Milan Italy
| | - Gloria Tamborini
- Department of Echocardiography IRCCS Centro Cardiologico Monzino Milan Italy
| | - Manuela Muratori
- Department of Echocardiography IRCCS Centro Cardiologico Monzino Milan Italy
| | - Mauro Pepi
- Department of Cardiac Imaging, IRCCS Centro Cardiologico Monzino Clinical Area Manager Milan Italy
| | - Gianluca Polvani
- Department of Cardiovascular Surgery IRCCS Centro Cardiologico Monzino Milan Italy
- Department of Surgical and Dental Biomedical Sciences University of Milan Milan Italy
| | - Marco Agrifoglio
- Department of Cardiovascular Surgery IRCCS Centro Cardiologico Monzino Milan Italy
- Department of Surgical and Dental Biomedical Sciences University of Milan Milan Italy
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10
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Vamvakidou A, Annabi MS, Pibarot P, Plonska-Gosciniak E, Almeida AG, Guzzetti E, Dahou A, Burwash IG, Koschutnik M, Bartko PE, Bergler-Klein J, Mascherbauer J, Orwat S, Baumgartner H, Cavalcante J, Pinto F, Kukulski T, Kasprzak JD, Clavel MA, Flachskampf FA, Senior R. Clinical Value of Stress Transaortic Flow Rate During Dobutamine Echocardiography in Reduced Left Ventricular Ejection Fraction, Low-Gradient Aortic Stenosis: A Multicenter Study. Circ Cardiovasc Imaging 2021; 14:e012809. [PMID: 34743529 DOI: 10.1161/circimaging.121.012809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Low rest transaortic flow rate (FR) has been shown previously to predict mortality in low-gradient aortic stenosis. However limited prognostic data exists on stress FR during low-dose dobutamine stress echocardiography. We aimed to assess the value of stress FR for the detection of aortic valve stenosis (AS) severity and the prediction of mortality. METHODS This is a multicenter cohort study of patients with reduced left ventricular ejection fraction and low-gradient aortic stenosis (aortic valve area <1 cm2 and mean gradient <40 mm Hg) who underwent low-dose dobutamine stress echocardiography to identify the AS severity and presence of flow reserve. The outcome assessed was all-cause mortality. RESULTS Of the 287 patients (mean age, 75±10 years; males, 71%; left ventricular ejection fraction, 31±10%) over a mean follow-up of 24±30 months there were 127 (44.3%) deaths and 147 (51.2%) patients underwent aortic valve intervention. Higher stress FR was independently associated with reduced risk of mortality (hazard ratio, 0.97 [95% CI, 0.94-0.99]; P=0.01) after adjusting for age, chronic kidney disease, heart failure symptoms, aortic valve intervention, and rest left ventricular ejection fraction. The minimum cutoff for prediction of mortality was stress FR 210 mL/s. Following adjustment to the same important clinical and echocardiographic parameters, among the three criteria of AS severity during stress, ie, the guideline definition of aortic valve area <1cm2 and aortic valve mean gradient ≥40 mm Hg, or aortic valve mean gradient ≥40 mm Hg, or the novel definition of aortic valve area <1 cm2 at stress FR ≥210 mL/s, only the latter was independently associated with mortality (hazard ratio, 1.72 [95% CI, 1.05-2.82]; P=0.03). Furthermore aortic valve area <1cm2 at stress FR ≥210 mL/s was the only severe aortic stenosis criterion that was associated with improved outcome following aortic valve intervention (P<0.001). Guideline-defined stroke volume flow reserve did not predict mortality. CONCLUSIONS Stress FR during low-dose dobutamine stress echocardiography was useful for the detection of both AS severity and flow reserve and was associated with improved prediction of outcome following aortic valve intervention.
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Affiliation(s)
- Anastasia Vamvakidou
- Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom (A.V., R.S.).,National Heart and Lung Institute, Imperial College, London, United Kingdom (A.V., R.S.).,Department of Cardiovascular Research, Northwick Park Hospital, Harrow, United Kingdom (A.V., R.S.)
| | - Mohamed-Salah Annabi
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Canada (M.-S.A., P.P., E.G., A.D., J.C., M.-A.C.)
| | - Phillipe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Canada (M.-S.A., P.P., E.G., A.D., J.C., M.-A.C.)
| | | | - Ana G Almeida
- Lisbon University, Hospital Santa Maria/CHULN, Portugal (A.G.A., F.P.)
| | - Ezequiel Guzzetti
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Canada (M.-S.A., P.P., E.G., A.D., J.C., M.-A.C.)
| | - Abdellaziz Dahou
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Canada (M.-S.A., P.P., E.G., A.D., J.C., M.-A.C.)
| | - Ian G Burwash
- University of Ottawa Heart Institute, Canada (I.G.B.)
| | - Matthias Koschutnik
- Department of Cardiology, Medical University of Vienna, Austria (M.K., P.E.B., J.B.-K.)
| | - Philipp E Bartko
- Department of Cardiology, Medical University of Vienna, Austria (M.K., P.E.B., J.B.-K.)
| | - Jutta Bergler-Klein
- Department of Cardiology, Medical University of Vienna, Austria (M.K., P.E.B., J.B.-K.)
| | - Julia Mascherbauer
- Department of Internal Medicine 3, Karl Landsteiner University of Health Sciences, University Hospital St. Polten, Krems, Austria (J.M.)
| | - Stefan Orwat
- Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Germany (S.O., H.B.)
| | - Helmut Baumgartner
- Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Germany (S.O., H.B.)
| | - Joao Cavalcante
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Canada (M.-S.A., P.P., E.G., A.D., J.C., M.-A.C.)
| | - Fausto Pinto
- Lisbon University, Hospital Santa Maria/CHULN, Portugal (A.G.A., F.P.)
| | - Tomasz Kukulski
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Medical University, Zabrze, Poland (T.K.)
| | - Jaroslaw D Kasprzak
- I Department of Cardiology, Medical University of Lodz, Bieganski Hospital, Poland (J.D.K.)
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Canada (M.-S.A., P.P., E.G., A.D., J.C., M.-A.C.)
| | - Frank A Flachskampf
- Department of Medical Sciences, Uppsala University, Sweden (F.A.F.).,Department of Clinical Physiology, Akademiska University Hospital, Uppsala, Sweden (F.A.F.)
| | - Roxy Senior
- Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom (A.V., R.S.).,National Heart and Lung Institute, Imperial College, London, United Kingdom (A.V., R.S.).,Department of Cardiovascular Research, Northwick Park Hospital, Harrow, United Kingdom (A.V., R.S.)
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11
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Shah BN, Senior R. Discordant moderate aortic stenosis: is it clinically important? Open Heart 2021; 8:openhrt-2021-001749. [PMID: 34625466 PMCID: PMC8504345 DOI: 10.1136/openhrt-2021-001749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/23/2021] [Indexed: 11/23/2022] Open
Affiliation(s)
- Benoy Nalin Shah
- Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Roxy Senior
- Department of Cardiology, Royal Brompton Hospital, London, UK
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12
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Moseley AD, Ahart ZC, Harris DM. Comparison of transvalvular flow rate in aortic stenosis subtypes. Echocardiography 2021; 38:1618-1623. [PMID: 34510510 DOI: 10.1111/echo.15187] [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: 05/07/2021] [Revised: 07/26/2021] [Accepted: 08/15/2021] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVES Evaluate ET and TVFR in normal patients, PLFLGAS, LGLFAS, and classic pre and post TAVR. BACKGROUND Severe aortic stenosis (AS) is defined echocardiographically. Generating a pressure gradient to meet diagnostic criteria is dependent on left ventricular contractility, stroke volume, and ejection time. Abnormalities in these decrease the mean pressure gradient across the valve creating pathology termed low flow, low gradient AS. This occurs in two subtypes, low ejection fraction LFLGAS and paradoxical LFLGAS (PLFLGAS), in which EF is normal but stroke volume is < 35 ml/m2 . Paradoxical LFLGAS is difficult to diagnose and does not have a confirmatory echocardiographic parameter. Transvalvular flow rate (TVFR), which is defined as stroke volume divided by the ejection time, provides a direct measure of flow across the aortic valve. METHODS A retrospective study of patients who underwent transcatheter aortic valve replacement (TAVR) at the University of Cincinnati Medical Center between 2016 and 2019 was performed. Patients were classified by AS subtype. ET and TVFR were measured pre and post TAVR and statistically compared using SPSS statistics software and ANOVA analysis. RESULTS Pre TAVR TVFR in the normal population, severe AS population, and LFLGAS were not significantly different. The pre TAVR TVFR in paradoxical LFLGAS patients was significantly lower than other groups. TVFR improved to the greatest degree post TAVR in PLFLGAS but did not meet statistical significance. CONCLUSIONS The significantly lower TVFR demonstrated in PLFLGAS provides a comprehensive, direct measurement of aortic valve hemodynamics and PLFLGAS pathology and can aid in diagnosis.
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Affiliation(s)
- Alex D Moseley
- Division of Cardiovascular Health and Disease, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Zachary C Ahart
- Department of Internal Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - David M Harris
- Division of Cardiovascular Health and Disease, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
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13
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Alkurashi AK, Pislaru SV, Thaden JJ, Collins JD, Foley TA, Greason KL, Eleid MF, Sandhu GS, Alkhouli MA, Asirvatham SJ, Cha YM, Williamson EE, Crestanello JA, Pellikka PA, Oh JK, Nkomo VT. Doppler Mean Gradient Is Discordant to Aortic Valve Calcium Scores in Patients with Atrial Fibrillation Undergoing Transcatheter Aortic Valve Replacement. J Am Soc Echocardiogr 2021; 35:116-123. [PMID: 34506919 DOI: 10.1016/j.echo.2021.08.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 08/17/2021] [Accepted: 08/30/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Doppler mean gradient (MG) may underestimate aortic stenosis (AS) severity when obtained during atrial fibrillation (AF) because of lower forward flow compared with sinus rhythm (SR). Whether AS is more advanced at the time of referral for aortic valve intervention in AF compared with SR is unknown. The aim of this study was to examine flow-independent computed tomographic aortic valve calcium scores (AVCS) and their concordance to MG in AF versus SR in patients undergoing transcatheter aortic valve replacement (TAVR). METHODS Patients who underwent TAVR from 2016 to 2020 for native valve severe AS with left ventricular ejection fraction ≥ 50% were identified from an institutional TAVR database. MGs during AF and SR in high-gradient AS (HGAS) and low-gradient AS (LGAS) were compared with AVCS (AVCS/MG ratio). AVCS were obtained within 90 days of pre-TAVR echocardiography. RESULTS Six hundred thirty-three patients were included; median age was 82 years (interquartile range [IQR], 76-86 years), and 46% were women. AF was present in 109 (17%) and SR in 524 (83%) patients during echocardiography. Aortic valve area index was slightly smaller in AF versus SR (0.43 cm2/m2 [IQR, 0.39-0.47 cm2/m2] vs 0.46 cm2/m2 [IQR, 0.41-0.51 cm2/m2], P = .0003). Stroke volume index, transaortic flow rate, and MG were lower in AF (P < .0001 for all). AVCS were higher in men with AF compared with SR (3,510 Agatston units [AU] [IQR, 2,803-4,030 AU] vs 2,722 AU [IQR, 2,180-3,467 AU], P < .0001) in HGAS but not in LGAS. AVCS were not different in women with AF versus SR. Overall AVCS/MG ratios were higher in AF versus SR in HGAS and LGAS (P < .03 for all), except in women with LGAS. CONCLUSIONS AVCS were higher than expected by MG in AF compared with SR. The very high AVCS in men with AF and HGAS at the time of TAVR suggests late diagnosis of severe AS because of underestimated AS severity during progressive AS and/or late referral to TAVR. Additional studies are needed to examine the extent to which echocardiography may be underestimating AS severity in AF.
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Affiliation(s)
- Adham K Alkurashi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Thomas A Foley
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gurpreet S Sandhu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mohamad A Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Yong-Mei Cha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
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14
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Bansal P, Maini A, Abbas A, Pibarot P, Maini B, Khalili H. Transaortic Flow in Aortic Stenosis: Stroke Volume Index versus Transaortic Flow Rate. J Am Soc Echocardiogr 2021; 34:1317-1320. [PMID: 34461252 DOI: 10.1016/j.echo.2021.08.016] [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: 06/01/2021] [Revised: 08/19/2021] [Accepted: 08/19/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Priya Bansal
- University of Southern California + LA County, Los Angeles, California; Florida Atlantic University, Boca Raton, Florida
| | - Aneel Maini
- Georgetown University School of Medicine, Washington, District of Columbia
| | - Amr Abbas
- William Beaumont Hospital, Royal Oak, Michigan
| | | | - Brijeshwar Maini
- Delray Medical Center, Delray Beach, Florida; Florida Atlantic University, Boca Raton, Florida
| | - Houman Khalili
- Delray Medical Center, Delray Beach, Florida; Florida Atlantic University, Boca Raton, Florida
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15
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Saeed S, Vamvakidou A, Zidros S, Papasozomenos G, Lysne V, Khattar RS, Senior R. Sex differences in transaortic flow rate and association with all-cause mortality in patients with severe aortic stenosis. Eur Heart J Cardiovasc Imaging 2021; 22:977-982. [PMID: 33734325 DOI: 10.1093/ehjci/jeab045] [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: 10/25/2020] [Accepted: 03/03/2021] [Indexed: 11/14/2022] Open
Abstract
AIMS It is not known whether transaortic flow rate (FR) in aortic stenosis (AS) differs between men and women, and whether the commonly used cut-off of 200 mL/s is prognostic in females. We aimed to explore sex differences in the determinants of FR, and determine the best sex-specific cut-offs for prediction of all-cause mortality. METHODS AND RESULTS Between 2010 and 2017, a total of 1564 symptomatic patients (mean age 76 ± 13 years, 51% men) with severe AS were prospectively included. Mean follow-up was 35 ± 22 months. The prevalence of cardiovascular disease was significantly higher in men than women (63% vs. 42%, P < 0.001). Men had higher left ventricular mass and lower left ventricular ejection fraction compared to women (both P < 0.001). Men were more likely to undergo an aortic valve intervention (AVI) (54% vs. 45%, P = 0.001), while the death rates were similar (42.0% in men and 40.6% in women, P = 0.580). A total of 779 (49.8%) patients underwent an AVI in which 145 (18.6%) died. In a multivariate Cox regression analysis, each 10 mL/s decrease in FR was associated with a 7% increase in hazard ratio (HR) for all-cause mortality (HR 1.07; 95% CI 1.03-1.11, P < 0.001). The best cut-off value of FR for prediction of all-cause mortality was 179 mL/s in women and 209 mL/s in men. CONCLUSION Transaortic FR was lower in women than men. In the group undergoing AVI, lower FR was associated with increased risk of all-cause mortality, and the optimal cut-off for prediction of all-cause mortality was lower in women than men.
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Affiliation(s)
- Sahrai Saeed
- Department of Cardiology, Royal Brompton Hospital, London, UK.,Department of Cardiology, Northwick Park Hospital, Harrow, UK.,Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Anastasia Vamvakidou
- Department of Cardiology, Royal Brompton Hospital, London, UK.,Department of Cardiology, Northwick Park Hospital, Harrow, UK.,National Heart and Lung Institute, Imperial College, London, UK
| | - Spyridon Zidros
- Department of Cardiology, Northwick Park Hospital, Harrow, UK
| | | | - Vegard Lysne
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Rajdeep S Khattar
- Department of Cardiology, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
| | - Roxy Senior
- Department of Cardiology, Royal Brompton Hospital, London, UK.,Department of Cardiology, Northwick Park Hospital, Harrow, UK.,National Heart and Lung Institute, Imperial College, London, UK
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16
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Sen J, Huynh Q, Stub D, Neil C, Marwick TH. Prognosis of Severe Low-Flow, Low-Gradient Aortic Stenosis by Stroke Volume Index and Transvalvular Flow Rate. JACC Cardiovasc Imaging 2021; 14:915-927. [PMID: 33744157 DOI: 10.1016/j.jcmg.2020.12.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 12/10/2020] [Accepted: 12/21/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES This study determined whether flow state classified by stroke volume index (SVi) or transvalvular flow rate (FR) improved risk stratification of all-cause mortality, hospitalization due to heart failure, and aortic valvular interventions for patients with severe aortic stenosis (AS). BACKGROUND SVi is a widely accepted classification for flow state in severe low-flow, low-gradient (LFLG) AS. Recent studies suggest that FR more closely approximates true AS severity and provides more useful prognostication than SVi. METHODS Patients with severe AS over a 7-year period were subclassified by echocardiographic parameters. LFLG-AS was defined as severe AS (aortic valve area index [AVAi]: <0.6 cm2/m2), with a mean transvalvular pressure gradient of <40 mm Hg in the setting of low flow state: SVi of <35 ml/m2 and/or FR of <200 ml/s and subclassified into preserved (≥50%; paradoxical) or reduced (<50%; classical) left ventricular ejection fraction (LVEF). RESULTS Among 621 consecutive patients with severe AS, the proportions of patients classified as LFLG-AS were different between SVi and FR (p < 0.001). Classification using SVi, FR, and LVEF was a strong predictor of the composite endpoint at the 2-year follow-up. The addition of SVi to the echocardiographic and clinical model provided significant improvement in reclassification (net reclassification improvement: 0.089; 95% confidence interval [CI]: 0.045 to 0.133; p = 0.04), whereas addition of FR did not (net reclassification improvement: 0.061; 95% CI: 0.016 to 0.106; p = 0.17). C-statistics indicated improved risk discrimination when AVAi, LVEF, and SVi or FR were added as predictive variables to the clinical model (p = 0.006). CONCLUSIONS Low SVi or FR was associated with adverse cardiovascular events and showed improvement in discrimination, but only SVi, not FR, significantly improved risk reclassification compared to other conventional clinical and echocardiographic predictors. This suggests that FR is not superior to SVi in distinguishing true severe from pseudosevere forms of AS and identification of patients with LFLG-AS who have worse outcomes.
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Affiliation(s)
- Jonathan Sen
- Baker Heart and Diabetes Institute, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia; Western Health, Melbourne, Australia
| | - Quan Huynh
- Baker Heart and Diabetes Institute, Melbourne, Australia; Monash University Alfred Health, Melbourne, Australia
| | - Dion Stub
- Baker Heart and Diabetes Institute, Melbourne, Australia; Western Health, Melbourne, Australia; Monash University Alfred Health, Melbourne, Australia
| | - Christopher Neil
- Baker Heart and Diabetes Institute, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia; Western Health, Melbourne, Australia
| | - Thomas H Marwick
- Baker Heart and Diabetes Institute, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia; Western Health, Melbourne, Australia; Monash University Alfred Health, Melbourne, Australia.
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17
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Low-Flow Aortic Stenosis: Flow Rate Does Not Replace But Could Refine Stroke Volume Index. JACC Cardiovasc Imaging 2021; 14:928-930. [PMID: 33744151 DOI: 10.1016/j.jcmg.2021.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 01/28/2021] [Accepted: 01/29/2021] [Indexed: 11/24/2022]
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18
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Contorni F, Fineschi M, Iadanza A, Santoro A, Mandoli GE, Cameli M. How to deal with low-flow low-gradient aortic stenosis and reduced left ventricle ejection fraction: from literature review to tips for clinical practice. Heart Fail Rev 2021; 27:697-709. [PMID: 33683509 PMCID: PMC8898219 DOI: 10.1007/s10741-021-10090-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2021] [Indexed: 01/01/2023]
Abstract
Low-flow low-gradient aortic stenosis (LFLG AS) with reduced left ventricle ejection fraction (LVEF) is still a diagnostic and therapeutic challenge. The aim of this paper is to review the latest evidences about the assessment of the valvular disease, usually difficult because of the low-flow status, and the therapeutic options. Special emphasis is given to the available diagnostic tools for the characterization of LFLG AS without functional reserve at stress echocardiography and to the factors that clinicians should evaluate to choose between surgical aortic valve repair, transcatheter aortic valve implantation, or medical therapy.
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Affiliation(s)
- F Contorni
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy.
| | - M Fineschi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - A Iadanza
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - A Santoro
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - G E Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - M Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
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19
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Namasivayam M, He W, Churchill TW, Capoulade R, Liu S, Lee H, Danik JS, Picard MH, Pibarot P, Levine RA, Hung J. Transvalvular Flow Rate Determines Prognostic Value of Aortic Valve Area in Aortic Stenosis. J Am Coll Cardiol 2020; 75:1758-1769. [PMID: 32299587 DOI: 10.1016/j.jacc.2020.02.046] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 02/01/2020] [Accepted: 02/14/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Aortic valve area (AVA) ≤1.0 cm2 is a defining characteristic of severe aortic stenosis (AS). AVA can be underestimated at low transvalvular flow rate. Yet, the impact of flow rate on prognostic value of AVA ≤1.0 cm2 is unknown and is not incorporated into AS assessment. OBJECTIVES This study aimed to evaluate the effect of flow rate on prognostic value of AVA in AS. METHODS In total, 1,131 patients with moderate or severe AS and complete clinical follow-up were included as part of a longitudinal database. The effect of flow rate (ratio of stroke volume to ejection time) on prognostic value of AVA ≤1.0 cm2 for time to death was evaluated, adjusting for confounders. Sensitivity analysis was performed to identify the optimal cutoff for prognostic threshold of AVA. The findings were validated in a separate external longitudinal cohort of 939 patients. RESULTS Flow rate had a significant effect on prognostic value of AVA. AVA ≤1.0 cm2 was not prognostic for mortality (p = 0.15) if AVA was measured at flow rates below median (≤242 ml/s). In contrast, AVA ≤1.0 cm2 was highly prognostic for mortality (p = 0.003) if AVA was measured at flow rates above median (>242 ml/s). Findings were irrespective of multivariable adjustment for age, sex, and surgical/transcatheter aortic valve replacement (as time-dependent covariates); comorbidities; medications; and echocardiographic features. AVA ≤1.0 cm2 was also not an independent predictor of mortality below median flow rate in the validation cohort. The optimal flow rate cutoff for prognostic threshold was 210 ml/s. CONCLUSIONS Transvalvular flow rate determines prognostic value of AVA in AS. AVA measured at low flow rate is not a good prognostic marker and therefore not a good diagnostic marker for truly severe AS. Flow rate assessment should be incorporated into clinical diagnosis, classification, and prognosis of AS.
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Affiliation(s)
- Mayooran Namasivayam
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. https://twitter.com/MayoNamasivayam
| | - Wei He
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy W Churchill
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Romain Capoulade
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Université de Nantes, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000, Nantes, France; Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Shiying Liu
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hang Lee
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jacqueline S Danik
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael H Picard
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Philippe Pibarot
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Robert A Levine
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Judy Hung
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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20
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Barbieri A, Antonini-Canterin F, Pepi M, Monte IP, Trocino G, Barchitta A, Ciampi Q, Cresti A, Miceli S, Petrella L, Benedetto F, Zito C, Benfari G, Bursi F, Malagoli A, Bartolacelli Y, Mantovani F, Clavel MA. Discordant Echocardiographic Grading in Low Gradient Aortic Stenosis (DEGAS Study) From the Italian Society of Echocardiography and Cardiovascular Imaging Research Network: Rationale and Study Design. J Cardiovasc Echogr 2020; 30:52-61. [PMID: 33282641 PMCID: PMC7706377 DOI: 10.4103/jcecho.jcecho_68_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 07/13/2020] [Indexed: 11/04/2022] Open
Abstract
Background Low-gradient aortic stenosis (LG-AS) is characterized by the combination of an aortic valve area compatible with severe stenosis and a low transvalvular mean gradient with low-flow state (i.e., indexed stroke volume <35 mL/m2) in the presence of reduced (classical low-flow AS) or preserved (paradoxical low-flow AS) ejection fraction. Furthermore, the occurrence of a normal-flow LG-AS is still advocated by many authors. Within this diagnostic complexity, the diagnosis of severe AS remains challenging. Objective The general objective of the Discordant Echocardiographic Grading in Low-gradient AS (DEGAS Study) study will be to assess the prevalence of true severe AS in this population and validate new parameters to improve the assessment and the clinical decision-making in patients with LG-AS. Methods and Analyses The DEGAS Study of the Italian Society of Echocardiography and Cardiovascular Imaging is a prospective, multicenter, observational diagnostic study that will enroll consecutively adult patients with LG-AS over 2 years. AS severity will be ideally confirmed by a multimodality approach, but only the quantification of calcium score by multidetector computed tomography will be mandatory. The primary clinical outcome variable will be 12-month all-cause mortality. The secondary outcome variables will be (i) 30-day mortality (for patients treated by Surgical aortic valve replacement or TAVR); (ii) 12-month cardiovascular mortality; (iii) 12-month new major cardiovascular events such as myocardial infarction, stroke, vascular complications, and rehospitalization for heart failure; and (iv) composite endpoint of cardiovascular mortality and hospitalization for heart failure. Data collection will take place through a web platform (REDCap), absolutely secure based on current standards concerning the ethical requirements and data integrity.
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Affiliation(s)
- Andrea Barbieri
- Division of Cardiology, Department of Diagnostics, Clinical and Public Health Medicine, Policlinico University Hospital of Modena, Milano, Italy
| | - Francesco Antonini-Canterin
- Rehabilitative Cardiology, Ospedale Riabilitativo di Alta Specializzazione di Motta di Livenza (TV), Milano, Italy
| | - Mauro Pepi
- Monzino Cardiology Center, IRCCS, Milano, Italy
| | | | - Giuseppe Trocino
- Cardiology, Hospital of Desio, S. Antonio Hospital, AO Padova, Italy
| | | | | | - Alberto Cresti
- Cardiology, Dip. Cardio Neuro Vascolare Asl sudest Toscana, Hospital of Grosseto, Italy
| | | | | | - Frank Benedetto
- Cardiology, G.O.M. "Bianchi Melacrino Morelli", Reggio Calabria, Italy
| | - Concetta Zito
- Department of Clinical and Experimental Medicine - Section of Cardiology, G. Martino General Hospital, University of Messina, Italy
| | - Giovanni Benfari
- Section of Cardiology, Department of Medicine, University of Verona, Italy
| | - Francesca Bursi
- Division of Cardiology, Heart and Lung Department, San Paolo Hospital, ASST Santi Paolo and Carlo, University of Milan, Italy
| | | | - Ylenia Bartolacelli
- Pediatric and Adult Congenital Heart Cardiac Surgery, S.Orsola Malpighi Hospital, University of Bologna, Italy
| | | | - Marie-Annick Clavel
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Quebec City, Quebec, Canada
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21
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Left ventricular output indices in hospitalized heart failure: when "simpler" may not mean "better". Int J Cardiovasc Imaging 2020; 37:59-68. [PMID: 32734497 DOI: 10.1007/s10554-020-01946-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 07/20/2020] [Indexed: 10/23/2022]
Abstract
Assessment of left ventricular (LV) output in hospitalized patients with heart failure (HF) is important to determine prognosis. Although echocardiographic LV ejection fraction (EF) is generally used to this purpose, its prognostic value is limited. In this investigation LV-EF was compared with other echocardiographic per-beat measures of LV output, including non-indexed stroke volume (SV), SV index (SVI), stroke distance (SD), ejection time (ET), and flow rate (FR), to determine the best predictor of all-cause mortality in patients hospitalized with HF. A final cohort of 350 consecutive patients hospitalized with HF who underwent echocardiography during hospitalization was studied. At a median follow-up of 2.7 years, 163 patients died. Non-survivors at follow-up had lower SD, SVI and SV, but not ET, FR and LV-EF than survivors. At multivariate analysis, only age, systolic blood pressure, chronic kidney disease, chronic obstructive pulmonary disease, use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and SVI remained significantly associated with outcome [HR for SVI 1.13 (1.04-1.22), P = 0.003]. In particular, for each 5 ml/m2 decrease in SVI, a 13% increase in risk of mortality for any cause was observed. SVI is a powerful prognosticator in HF patients, better than other per-beat measures, which may be simpler but partial or incomplete descriptors of LV output. SVI, therefore, should be considered for the routine echocardiographic evaluation of patients hospitalized with HF to predict prognosis.
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22
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Anand V, Mankad SV, Eleid M. What Is New in Low Gradient Aortic Stenosis: Surgery, TAVR, or Medical Therapy? Curr Cardiol Rep 2020; 22:78. [DOI: 10.1007/s11886-020-01341-x] [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] [Indexed: 01/08/2023]
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23
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Namasivayam M, Picard MH. Flow Rate in Aortic Stenosis: Clinical Tool, Hemodynamic Insight, or Both? J Am Soc Echocardiogr 2020; 33:449-451. [DOI: 10.1016/j.echo.2020.01.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 01/28/2020] [Indexed: 12/11/2022]
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25
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Hirasawa K, Izumo M, Suzuki K, Suzuki T, Ohara H, Watanabe M, Sato Y, Kamijima R, Nobuoka S, Akashi YJ. Value of Transvalvular Flow Rate during Exercise in Asymptomatic Patients with Aortic Stenosis. J Am Soc Echocardiogr 2020; 33:438-448. [DOI: 10.1016/j.echo.2019.11.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 11/13/2019] [Accepted: 11/17/2019] [Indexed: 12/14/2022]
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Guzzetti E, Clavel MA, Pibarot P. Importance of Flow in Risk Stratification of Aortic Stenosis. Can J Cardiol 2019; 36:27-29. [PMID: 31810743 DOI: 10.1016/j.cjca.2019.10.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 10/15/2019] [Accepted: 10/15/2019] [Indexed: 11/18/2022] Open
Affiliation(s)
- Ezequiel Guzzetti
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Québec City, Québec, Canada
| | - Marie-Annick Clavel
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Québec City, Québec, Canada
| | - Philippe Pibarot
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Québec City, Québec, Canada.
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Vollema EM, Delgado V, Bax JJ. Echocardiography in Transcatheter Aortic Valve Replacement. Heart Lung Circ 2019; 28:1384-1399. [DOI: 10.1016/j.hlc.2018.12.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 12/11/2018] [Accepted: 12/16/2018] [Indexed: 02/06/2023]
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O’Sullivan CJ, Spitzer E. Transaortic Flow Rate Versus Stroke Volume Index in Low-Gradient Aortic Stenosis. JACC Cardiovasc Imaging 2019; 12:1725-1727. [DOI: 10.1016/j.jcmg.2018.01.017] [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: 01/08/2018] [Accepted: 01/09/2018] [Indexed: 10/17/2022]
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Burkule N. Stress echocardiography in aortic stenosis. JOURNAL OF THE INDIAN ACADEMY OF ECHOCARDIOGRAPHY & CARDIOVASCULAR IMAGING 2019. [DOI: 10.4103/jiae.jiae_41_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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31
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Vamvakidou A, Jin W, Danylenko O, Pradhan J, Li W, West C, Khattar R, Senior R. Impact of Pre-Intervention Transaortic Flow Rate Versus Stroke Volume Index on Mortality Across the Hemodynamic Spectrum of Severe Aortic Stenosis. JACC Cardiovasc Imaging 2019; 12:205-206. [DOI: 10.1016/j.jcmg.2018.11.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 11/05/2018] [Accepted: 11/07/2018] [Indexed: 12/01/2022]
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Lazaros G, Drakopoulou M, Tousoulis D. Transaortic Flow in Aortic Stenosis: Stroke Volume Index versus Flow Rate. Cardiology 2018; 141:71-73. [DOI: 10.1159/000494051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 09/24/2018] [Indexed: 11/19/2022]
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