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De Felice F, Paolucci L, Musto C, Nazzaro MS, Chin D, Stio R, Pennacchi M, Adamo M, Chizzola G, Massussi M, Giannini C, Angelillis M, De Carlo M, Gorla R, Bedogni F, Bellini B, Montorfano M, Bruschi G, Merlanti B, Ferrara E, Poli A, Regazzoli D, Palmerini T, Iadanza A, Nicolini E, Toselli M, De Marco F, Gabrielli D. Eight-Year Outcomes of Patients With Reduced Left Ventricular Ejection Fraction Who Underwent Transcatheter Aortic Valve Replacement With a Self-Expanding Bioprosthesis. Am J Cardiol 2024; 232:57-64. [PMID: 39307331 DOI: 10.1016/j.amjcard.2024.09.015] [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: 09/02/2024] [Revised: 09/08/2024] [Accepted: 09/10/2024] [Indexed: 10/06/2024]
Abstract
Data deriving from patients who underwent TAVR between 2007 and 2017 in 13 Italian centers were prospectively collected. Patients were stratified in those with normal LVEF and reduced LVEF. The latter was further classified according to ischemic or nonischemic etiology. The primary end point was a composite of all-cause death and rehospitalizations; the secondary end points were the isolated composers of the primary end point and cardiac death. Overall, 2,626 patients were included in the analysis: 68.1% with normal LVEF and 31.9% with reduced LVEF. At 8 years, reduced LVEF was significantly associated with the primary end point (adjusted hazard ratio 1.17, 95% confidence interval 1.06 to 1.29). Consistent findings were evident for the composite end point. No differences in these trends were found at the 30-day landmark analyses. Compared with nonischemic etiology, ischemic reduced LVEF was associated with an increased risk of cardiac death (adjusted hazard ratio 1.43, 95% confidence interval 1.02 to 2.02). In conclusion, patients with reduced LVEF who underwent TAVR are exposed to a progressively increased risk of death and rehospitalizations, even at very long-term follow-up.
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Affiliation(s)
- Francesco De Felice
- Division of Interventional Cardiology, Azienda Ospedaliera S. Camillo Forlanini, Rome, Italy.
| | - Luca Paolucci
- Division of Interventional Cardiology, Azienda Ospedaliera S. Camillo Forlanini, Rome, Italy
| | - Carmine Musto
- Division of Interventional Cardiology, Azienda Ospedaliera S. Camillo Forlanini, Rome, Italy
| | - Marco Stefano Nazzaro
- Division of Interventional Cardiology, Azienda Ospedaliera S. Camillo Forlanini, Rome, Italy
| | - Diana Chin
- Division of Interventional Cardiology, Azienda Ospedaliera S. Camillo Forlanini, Rome, Italy
| | - Rocco Stio
- Division of Interventional Cardiology, Azienda Ospedaliera S. Camillo Forlanini, Rome, Italy
| | - Mauro Pennacchi
- Division of Interventional Cardiology, Azienda Ospedaliera S. Camillo Forlanini, Rome, Italy
| | - Marianna Adamo
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Giuliano Chizzola
- Cardiac Catheterization Laboratory and Cardiology, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Mauro Massussi
- Cardiac Catheterization Laboratory and Cardiology, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Cristina Giannini
- Interventional Cardiology Section, Cardiothoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Marco Angelillis
- Interventional Cardiology Section, Cardiothoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Marco De Carlo
- Interventional Cardiology Section, Cardiothoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Riccardo Gorla
- Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Francesco Bedogni
- Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Barbara Bellini
- Interventional Cardiology Unit IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Matteo Montorfano
- Interventional Cardiology Unit IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giuseppe Bruschi
- Cardiac Surgery, De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy
| | - Bruno Merlanti
- Cardiac Surgery, De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy
| | - Erica Ferrara
- Interventional Cardiology Unit, Legnano Civil Hospital, Legnano, Italy
| | - Arnaldo Poli
- Interventional Cardiology Unit, Legnano Civil Hospital, Legnano, Italy
| | | | - Tullio Palmerini
- Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS University Hospital of Bologna, Policlinico S. Orsola, Bologna, Italy
| | - Alessandro Iadanza
- UOSA Cardiologia Interventistica, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Elisa Nicolini
- Interventional Cardiology, Azienda Ospedaliero-Universitaria delle Marche, Ancona, Italy
| | - Marco Toselli
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Federico De Marco
- Interventional Cardiology Department, IRCSS Centro Cardiologico Monzino, Milan, Italy
| | - Domenico Gabrielli
- Division of Interventional Cardiology, Azienda Ospedaliera S. Camillo Forlanini, Rome, Italy
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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; 22:152-161. [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] [MESH Headings] [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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Jonnala VR, Quadri HS, Pourafkari L, Fernandez SF, Iyer VS, Nader ND. Stroke volume index (SVI) predicts all-cause mortality following transcatheter aortic valve replacement (TAVR). CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00544-X. [PMID: 38902192 DOI: 10.1016/j.carrev.2024.06.014] [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: 01/03/2024] [Revised: 06/04/2024] [Accepted: 06/14/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Left ventricular systolic dysfunction in patients with severe aortic stenosis (AS) may result in low transvalvular gradients and underestimation of AS severity. A low-flow state may occur with reduced LVEF. Little is known about the implications of low compared to normal flow in patients with reduced LVEF undergoing transcatheter aortic valve replacement (TAVR). OBJECTIVES We compared survival rates with degree of flow across stenosed aortic valves and left ventricular dysfunction. We hypothesized that the stroke volume index (SVI) offers essential information regarding survival following TAVR. METHODS We retrospectively reviewed patients with LVEF <50 % undergoing TAVR at the Gates Vascular Institute in Buffalo, New York, from 2012 to 2017. We performed Receiver Operator Characteristics to examine the value of SVI in predicting the postoperative outcome of patients. Kaplan-Meier and Cox regression analyses were used to investigate the effect of a low-flow state on five-year survival in patients with systolic dysfunction undergoing TAVR. RESULTS Five-year survival following TAVR was decreased in patients with low-flow AS (SVI <35 mL/m2) compared to patients with normal flow. Seventy-four percent (n = 50) of patients with low-flow compared to 43 % (n = 22) of patients with normal flow were deceased five years post-TAVR (p ≤0.001). ROC curve indicated SVI to be a clinical predictor of five year survival (AUC 0.732, 95 % CI: 0.641-0.823, p < 0.001). CONCLUSION Patients with systolic dysfunction and low transvalvular flow AS had increased mortality five years following TAVR. These findings highlight a better prognosis in patients with normal flow and LV systolic dysfunction. CONDENSED ABSTRACT Low-flow aortic stenosis can occur with reduced left ventricular function. We compared survival rates of patients with known reduced left ventricular function in low-flow and normal flow aortic stenosis. This retrospective single-center study examined mortality rates following transcatheter aortic valve replacement. The mean gradient was not a predictor of mortality. This study shows patients with low-flow aortic stenosis have decreased five-year survival following valve replacement.
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Affiliation(s)
| | - Haroon S Quadri
- Department of Anesthesiology, University at Buffalo, Buffalo, NY, USA
| | - Leili Pourafkari
- Department of Anesthesiology, University at Buffalo, Buffalo, NY, USA; Lundquist Institute, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Stanley F Fernandez
- Department of Anesthesiology, University at Buffalo, Buffalo, NY, USA; Department of Medicine, Division of Cardiology, Jacob's School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Vijay S Iyer
- Department of Medicine, Division of Cardiology, Jacob's School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Nader D Nader
- Department of Anesthesiology, University at Buffalo, Buffalo, NY, USA.
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Sen J, Wang WYS, Ng ACT. The Unraveling Complexity: Atrial Fibrillation's Influence on Severe Aortic Stenosis. Am J Cardiol 2024; 215:72-73. [PMID: 38160918 DOI: 10.1016/j.amjcard.2023.12.041] [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: 11/20/2023] [Accepted: 12/01/2023] [Indexed: 01/03/2024]
Affiliation(s)
- Jonathan Sen
- Princess Alexandra Hospital, Queensland, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia; Department of Cardiometabolic Health, University of Melbourne, Melbourne, Australia; Faculty of Medicine, the University of Queensland, Melbourne, Australia
| | - William Y S Wang
- Princess Alexandra Hospital, Queensland, Australia; Faculty of Medicine, the University of Queensland, Melbourne, Australia
| | - Arnold C T Ng
- Princess Alexandra Hospital, Queensland, Australia; Faculty of Medicine, the University of Queensland, Melbourne, Australia.
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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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Onishi H, Izumo M, Nishikawa H, Suzuki T, Sato Y, Watanabe M, Kuwata S, Kamijima R, Naganuma T, Nakamura S, Akashi YJ. Prognostic value of transvalvular flow rate in patients with low-gradient severe aortic stenosis: A dobutamine stress echocardiography study. Echocardiography 2024; 41:e15712. [PMID: 37937359 DOI: 10.1111/echo.15712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 10/06/2023] [Accepted: 10/29/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUNDS There are limited data on the clinical relevance of transvalvular flow rate (Qmean ) at rest (Qrest) and at peak stress (Qstress ) during dobutamine stress echocardiography (DSE) in patients with low-gradient severe aortic stenosis (LG-SAS). METHODS We retrospectively analyzed the clinical data of patients with LG-SAS who underwent DSE. LG-SAS was defined as an aortic valve (AV) area index of < .6 cm2 /m2 and a mean AV pressure gradient (AVPG) of < 40 mm Hg. The primary endpoint included all-cause death and heart failure hospitalization. RESULTS Of 100 patients (mean age 79.5 ± 7.3 years; men, 45.0%; resting left ventricular ejection fraction [LVEF] 52.1% ± 15.9%; resting stroke volume index 35.8 ± 7.7 mL/m2 ; Qrest 171.8 ± 34.9 mL/s), the primary endpoint occurred in 51 patients during a median follow-up of 2.84 (interquartile range 1.01-5.21) years. When the study patients were divided into three subgroups based on Qrest and Qstress , the multivariate analysis showed that Qrest < 200 mL/s and Qstress ≥200 mL/s (hazard ratio 3.844; 95% confidence interval 1.143-12.930; p = .030), as well as Qrest and Qstress < 200 mL/s (hazard ratio 9.444; 95% confidence interval 2.420-36.850; p = .001), were significantly associated with unfavorable outcomes with Qrest and Qstress ≥200 mL/s as a reference after adjusting for resting LVEF, resting mean AVPG, chronic kidney disease, New York Heart Association functional class III/IV, and AV replacement. CONCLUSIONS Flow conditions based on the combination of Qrest and Qstress are helpful for risk stratification in LG-SAS patients.
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Affiliation(s)
- Hirokazu Onishi
- Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan
| | - Masaki Izumo
- Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Haruka Nishikawa
- Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Tomomi Suzuki
- Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Yukio Sato
- Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Mika Watanabe
- Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Shingo Kuwata
- Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Ryo Kamijima
- Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Toru Naganuma
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan
| | - Sunao Nakamura
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan
| | - Yoshihiro J Akashi
- Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan
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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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8
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Généreux P, Sharma RP, Cubeddu RJ, Aaron L, Abdelfattah OM, Koulogiannis KP, Marcoff L, Naguib M, Kapadia SR, Makkar RR, Thourani VH, van Boxtel BS, Cohen DJ, Dobbles M, Barnhart GR, Kwon M, Pibarot P, Leon MB, Gillam LD. The Mortality Burden of Untreated Aortic Stenosis. J Am Coll Cardiol 2023; 82:2101-2109. [PMID: 37877909 DOI: 10.1016/j.jacc.2023.09.796] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/06/2023] [Accepted: 09/08/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND The American College of Cardiology/American Heart Association guidelines recommend the assessment and grading of severity of aortic stenosis (AS) as mild, moderate, or severe, per echocardiogram, and recommend aortic valve replacement (AVR) when the AS is severe. OBJECTIVES The authors sought to describe mortality rates across the entire spectrum of untreated AS from a contemporary, large, real-world database. METHODS We analyzed a deidentified real-world data set including 1,669,536 echocardiographic reports (1,085,850 patients) from 24 U.S. hospitals (egnite Database, egnite). Patients >18 years of age were classified by diagnosed AS severity. Untreated mortality and treatment rates were examined with Kaplan-Meier (KM) estimates, with results compared using the log-rank test. Multivariate hazards analysis was performed to assess associations with all-cause mortality. RESULTS Among 595,120 patients with available AS severity assessment, the KM-estimated 4-year unadjusted, untreated, all-cause mortality associated with AS diagnosis of none, mild, mild-to-moderate, moderate, moderate-to-severe, or severe was 13.5% (95% CI: 13.3%-13.7%), 25.0% (95% CI: 23.8%-26.1%), 29.7% (95% CI: 26.8%-32.5%), 33.5% (95% CI: 31.0%-35.8%), 45.7% (95% CI: 37.4%-52.8%), and 44.9% (95% CI: 39.9%-49.6%), respectively. Results were similar when adjusted for informative censoring caused by treatment. KM-estimated 4-year observed treatment rates were 0.2% (95% CI: 0.2%-0.2%), 1.0% (95% CI: 0.7%-1.3%), 4.2% (95% CI: 2.0%-6.3%), 11.4% (95% CI: 9.5%-13.3%), 36.7% (95% CI: 31.8%-41.2%), and 60.7% (95% CI: 58.0%-63.3%), respectively. After adjustment, all degrees of AS severity were associated with increased mortality. CONCLUSIONS Patients with AS have high mortality risk across all levels of untreated AS severity. Aortic valve replacement rates remain low for patients with severe AS, suggesting that more research is needed to understand barriers to diagnosis and appropriate approach and timing for aortic valve replacement.
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Affiliation(s)
- Philippe Généreux
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA.
| | - Rahul P Sharma
- Stanford University School of Medicine, Stanford, California, USA
| | | | - Lucy Aaron
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA
| | - Omar M Abdelfattah
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA
| | | | - Leo Marcoff
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA
| | - Mostafa Naguib
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA
| | | | | | | | - Benjamin S van Boxtel
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA
| | - David J Cohen
- Cardiovascular Research Foundation, New York, New York, USA; St Francis Hospital and Heart Center, Roslyn, New York, USA
| | | | | | | | - Philippe Pibarot
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Martin B Leon
- Cardiovascular Research Foundation, New York, New York, USA; Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Linda D Gillam
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA
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9
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Jean G, Mogensen NSB, Clavel MA. Aortic Valvular Stenosis and Heart Failure: Advances in Diagnostic, Management, and Intervention. Heart Fail Clin 2023; 19:273-283. [PMID: 37230643 DOI: 10.1016/j.hfc.2023.02.005] [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: 05/27/2023]
Abstract
Up to 30% of patients with aortic stenosis (AS) present with heart failure (HF) symptoms with either reduced or preserved left ventricular ejection fraction. Many of these patients present with a low-flow state, reduced aortic-valve-area (≤1.0 cm2) with low aortic-mean-gradient and aortic-peak-velocity (<40 mm Hg and <4.0 m/s). Thus, determination of true severity is essential for correct management, and multi-imaging evaluation must be performed. Medical treatment of HF is imperative and should be optimized concurrently with the determination of AS-severity. Finally, AS should be treated according to guidelines, keeping in mind that HF and low-flow increase interventions risks.
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Affiliation(s)
- Guillaume Jean
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval (IUCPQ-UL)/ Québec Heart & Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec City, QC G1V 4G5, Canada
| | - Nils Sofus Borg Mogensen
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval (IUCPQ-UL)/ Québec Heart & Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec City, QC G1V 4G5, Canada; Department of Cardiology, Odense University Hospital, University of Southern Denmark, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval (IUCPQ-UL)/ Québec Heart & Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec City, QC G1V 4G5, Canada; Department of Cardiology, Odense University Hospital, University of Southern Denmark, J. B. Winsløws Vej 4, 5000 Odense, Denmark.
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10
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Cramariuc D, Bahlmann E, Gerdts E. Grading of Aortic Stenosis: Is it More Complicated in Women? Eur Cardiol 2022; 17:e21. [PMID: 36643071 PMCID: PMC9820123 DOI: 10.15420/ecr.2022.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/29/2022] [Indexed: 12/14/2022] Open
Abstract
Aortic stenosis (AS) is the most common valvular heart disease and the main indication for valvular replacement in older women. Correct AS grading is mandatory for an adequate selection of patients for both surgical and transcatheter aortic valve replacement. Women and men have different AS severity grades at the same level of aortic valve calcification. Moreover, besides having smaller cardiac volumes, left ventricular outflow tract and aortic size, women have a specific pattern of left ventricular structural and functional remodelling in response to the AS-related chronic pressure overload. Here, the sex-specific cardiac changes in AS that make AS grading more challenging in women, with consequences for the management and outcome of this group of patients, are reviewed.
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Affiliation(s)
- Dana Cramariuc
- Department of Heart Disease, Haukeland University HospitalBergen, Norway,Department of Clinical Science, University of BergenBergen, Norway
| | - Edda Bahlmann
- Department of Cardiology, Asklepios Kliniken St. GeorgHamburg, Germany
| | - Eva Gerdts
- Department of Clinical Science, University of BergenBergen, Norway
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11
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Stassen J, Ewe SH, Singh GK, Butcher SC, Hirasawa K, Amanullah MR, Pio SM, Sin KYK, Ding ZP, Sia CH, Chew NWS, Kong WKF, Poh KK, Leon MB, Pibarot P, Delgado V, Marsan NA, Bax JJ. Prevalence and Prognostic Implications of Discordant Grading and Flow-Gradient Patterns in Moderate Aortic Stenosis. J Am Coll Cardiol 2022; 80:666-676. [PMID: 35953133 DOI: 10.1016/j.jacc.2022.05.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/04/2022] [Accepted: 05/16/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND The prognostic implications of discordant grading in severe aortic stenosis (AS) are well known. However, the prevalence of different flow-gradient patterns and their prognostic implications in moderate AS are unknown. OBJECTIVES The purpose of this study was to investigate the occurrence and prognostic implications of different flow-gradient patterns in patients with moderate AS. METHODS Patients with moderate AS (aortic valve area >1.0 and ≤1.5 cm2) were identified and divided in 4 groups based on transvalvular mean gradient (MG), stroke volume index (SVi), and left ventricular ejection fraction (LVEF): concordant moderate AS (MG ≥20 mm Hg) and discordant moderate AS including 3 subgroups: normal-flow, low-gradient moderate AS (MG <20 mm Hg, SVi ≥35 mL/m2, and LVEF ≥50%); "paradoxical" low-flow, low-gradient moderate AS (MG <20 mm Hg, SVi <35 mL/m2, and LVEF ≥50%) and "classical" low-flow, low-gradient moderate AS (MG <20 mm Hg and LVEF <50%). The primary endpoint was all-cause mortality. RESULTS Of 1,974 patients (age 73 ± 10 years, 51% men) with moderate AS, 788 (40%) had discordant grading, and these patients showed significantly higher mortality rates than patients with concordant moderate AS (P < 0.001). On multivariable analysis, "paradoxical" low-flow, low-gradient (HR: 1.458; 95% CI: 1.072-1.983; P = 0.014) and "classical" low-flow, low-gradient (HR: 1.710; 95% CI: 1.270-2.303; P < 0.001) patterns but not the normal-flow, low-gradient moderate AS pattern were independently associated with all-cause mortality. CONCLUSIONS Discordant grading is frequently (40%) observed in patients with moderate AS. Low-flow, low-gradient patterns account for an important proportion of the discordant cases and are associated with increased mortality. These findings underline the need for better phenotyping patients with discordant moderate AS.
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Affiliation(s)
- Jan Stassen
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Cardiology, Jessa Hospital, Hasselt, Belgium
| | - See Hooi Ewe
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Gurpreet K Singh
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Steele C Butcher
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Kensuke Hirasawa
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Stephan M Pio
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Kenny Y K Sin
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Zee P Ding
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Nicholas W S Chew
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - William K F Kong
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Kian Keong Poh
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Martin B Leon
- Columbia University Irving Medical Center and Cardiovascular Research Foundation, New York, New York, USA
| | - Philippe Pibarot
- Department of Cardiology, Québec Heart and Lung Institute, Laval University, Quebec, Quebec, Canada
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Cardiology, National University Heart Center Singapore, Singapore; Turku Heart Center, University of Turku and Turku University Hospital, Turku, Finland.
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12
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Schwartzenberg S, Vatury M, Wiessman M, Shechter A, Morelli O, Ofek H, Kazum S, Kornowski R, Sagie A, Shapira Y. Severe aortic stenosis echocardiographic thresholds revisited. Echocardiography 2021; 38:2016-2024. [PMID: 34854128 DOI: 10.1111/echo.15241] [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: 05/29/2021] [Revised: 09/11/2021] [Accepted: 10/21/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND In view of inconsistencies in threshold values of severe aortic stenosis (AS) hemodynamic indices, it is unclear what is the relative contribution of each variable in a binary classification of AS based on aortic valve replacement (AVR) indication. We aimed to assess relative discriminative value and optimal threshold of each constituent hemodynamic parameter for this classification and confirm additional prognostic value. METHODS Echocardiography studies of 168 patients with ≥ moderate AS were included. AS types were dichotomized into Group-A, comprising moderate and Normal-Flow Low-Gradient (NFLG), and Group-B, comprising High-Gradient(HG), Low Ejection Fraction Low-Flow Low-Gradient(Low EF-LFLG), and Paradoxical Low-Flow Low-Gradient(PLFLG) AS. Aortic valve area (AVA), Doppler velocity index (DVI), peak aortic velocity, mean gradient, stroke volume index and transaortic flow rate(TFR) were assessed for A/B Group discrimination value and optimal thresholds were determined. Dichotomized values were assessed for predictive value for AVR or death. RESULTS C-statistic values for binary AS classification was .74-.9 for the tested variables. AVA and DVI featured the highest score, and SVI the lowest one. AVA≤.81 cm2 and DVI≤.249 had 87.6% and 86% respective sensitivity for Group B patients, and a similar specificity of 80.9%. During a mean follow-up of 9.1±10.1 months, each of the tested dichotomized variables except for SVI predicted AVR or death on multivariate analysis. CONCLUSION An AVA value ≤.81 cm2 or a DVI ≤ .249 threshold carry the highest discriminative value for severe AS in patients with aortic stenosis, translating into an independent prognostic value, and can be helpful in making clinical decisions.
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Affiliation(s)
- Shmuel Schwartzenberg
- The Department of Cardiology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Mordehay Vatury
- The Department of Cardiology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Maya Wiessman
- The Department of Cardiology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Alon Shechter
- The Department of Cardiology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Olga Morelli
- The Department of Cardiology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Hadas Ofek
- The Department of Cardiology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Shirit Kazum
- The Department of Cardiology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Ran Kornowski
- The Department of Cardiology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Alexander Sagie
- The Department of Cardiology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Yaron Shapira
- The Department of Cardiology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
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13
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Abstract
Aortic stenosis (AS) is defined as severe in the presence of: mean gradient ≥40 mmHg, peak aortic velocity ≥4 m/s, and aortic valve area (AVA) ≤1 cm2 (or an indexed AVA ≤0.6 cm2/m2). However, up to 40% of patients have a discrepancy between gradient and AVA, i.e. AVA ≤1 cm2 (indicating severe AS) and a moderate gradient: >20 and <40 mmHg (typical of moderate stenosis). This condition is called ‘low-gradient AS’ and includes very heterogeneous clinical entities, with different pathophysiological mechanisms. The diagnostic tools needed to discriminate the different low-gradient AS phenotypes include colour-Doppler echocardiography, dobutamine stress echocardiography, computed tomography scan for the definition of the calcium score, and recently magnetic resonance imaging. The prognostic impact of low-gradient AS is heterogeneous. Classical low-flow low-gradient AS [reduced left ventricular ejection fraction (LVEF)] has the worst prognosis, followed by paradoxical low-flow low-gradient AS (preserved LVEF). Conversely, normal-flow low-gradient AS is associated with a better prognosis. The indications of the guidelines recommend surgical or percutaneous treatment, depending on the risk and comorbidities of the individual patient, both for patients with classic low-flow low-gradient AS and for those with paradoxical low-flow low-gradient AS.
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Affiliation(s)
- Vittoria Rizzello
- Dipartimento Cardiovascolare, Unità di Cardiologia d’Urgenza e UTIC, Azienda Ospedaliera San Giovanni Addolorata, Roma, Italy
- Corresponding author.
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14
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Fan Y, Shen H, Stacey B, Zhao D, Applegate RJ, Kon ND, Kincaid EH, Gandhi SK, Pu M. Echocardiography and EuroSCORE II for the stratification of low-gradient severe aortic stenosis and preserved left ventricular ejection fraction. Int J Cardiovasc Imaging 2021; 37:3169-3176. [PMID: 34392468 PMCID: PMC8557199 DOI: 10.1007/s10554-021-02373-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 08/03/2021] [Indexed: 11/02/2022]
Abstract
The purpose of this study was to explore the utility of echocardiography and the EuroSCORE II in stratifying patients with low-gradient severe aortic stenosis (LG SAS) and preserved left ventricular ejection fraction (LVEF ≥ 50%) with or without aortic valve intervention (AVI). The study included 323 patients with LG SAS (aortic valve area ≤ 1.0 cm2 and mean pressure gradient < 40 mmHg). Patients were divided into two groups: a high-risk group (EuroSCORE II ≥ 4%, n = 115) and a low-risk group (EuroSCORE II < 4%, n = 208). Echocardiographic and clinical characteristics were analyzed. All-cause mortality was used as a clinical outcome during mean follow-up of 2 ± 1.3 years. Two-year cumulative survival was significantly lower in the high-risk group than the low-risk patients (62.3% vs. 81.7%, p = 0.001). AVI tended to reduce mortality in the high-risk patients (70% vs. 59%; p = 0.065). It did not significantly reduce mortality in the low-risk patients (82.8% with AVI vs. 81.2%, p = 0.68). Multivariable analysis identified heart failure, renal dysfunction and stroke volume index (SVi) as independent predictors for mortality. The study suggested that individualization of AVI based on risk stratification could be considered in a patient with LG SAS and preserved LVEF.
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Affiliation(s)
- Yan Fan
- Section on Cardiovascular Medicine, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.,First Hospital, Peking University, Beijing, China
| | - Hong Shen
- Section on Cardiovascular Medicine, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Brandon Stacey
- Section on Cardiovascular Medicine, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - David Zhao
- Section on Cardiovascular Medicine, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Robert J Applegate
- Section on Cardiovascular Medicine, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Neal D Kon
- Section of Cardiothoracic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, USA
| | - Edward H Kincaid
- Section of Cardiothoracic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, USA
| | - Sanjay K Gandhi
- Section on Cardiovascular Medicine, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Min Pu
- Section on Cardiovascular Medicine, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
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15
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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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