1
|
Tan JTA, He GS, Chia JLL, Tan GQX, Teo YN, Teo YH, Syn NL, Chai P, Wong RCC, Yeo TC, Kong WKF, Poh KK, Sia CH. Natural history of initially asymptomatic severe aortic stenosis: a one-stage meta-analysis. Clin Res Cardiol 2024:10.1007/s00392-024-02465-8. [PMID: 39009912 DOI: 10.1007/s00392-024-02465-8] [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: 07/03/2023] [Accepted: 05/16/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Current guidelines on the management strategy for patients with asymptomatic severe aortic stenosis (AS) remain unclear. This uncertainty stems from the lack of data regarding the natural history of these patients. To address this gap, we performed a systematic review and meta-analysis examining the natural history of asymptomatic severe AS patients receiving conservative treatment. METHODS The PubMed, Cochrane, and Embase databases were searched from inception to 24 January 2024 using the keywords "asymptomatic" AND "aortic" AND "stenosis". We included studies examining patients with asymptomatic severe AS. In interventional trials, only data from conservatively managed arms were collected. A one-stage meta-analysis was conducted using individual patient data reconstructed from published Kaplan-Meier curves. Sensitivity analysis was performed for major adverse cardiovascular outcomes in patients who remained asymptomatic throughout follow-up. RESULTS A total of 46 studies were included (n = 9545). The median time to the development of symptoms was 1.11 years (95% CI 0.90-1.53). 49.36% (40.85-58.59) of patients who were asymptomatic had suffered a major adverse cardiovascular event by 5 years. The median event-free time for heart failure hospitalization (HFH) was 5.50 years (95% CI 5.14-5.91) with 36.34% (95% CI 33.34-39.41) of patients experiencing an HFH by year 5. By 5 years, 79.81% (95% CI 69.26-88.58) of patients developed symptoms (angina, dyspnoea, syncope and others) and 12.36% (95% CI 10.01-15.22) of patients died of cardiovascular causes. For all-cause mortality, the median survival time was 9.15 years (95% CI 8.50-9.96) with 39.43% (CI 33.41-36.40) of patients dying by 5 years. The median time to AVR was 4.77 years (95% CI 4.39-5.17), with 52.64% (95% CI 49.85-55.48) of patients requiring an AVR by 5 years. CONCLUSION Our results reveal poor cardiovascular outcomes for patients with asymptomatic severe AS on conservative treatment. A significant proportion eventually requires an AVR. Further research is needed to determine if early intervention with AVR is more effective than conservative treatment.
Collapse
Affiliation(s)
- Joshua Teik Ann Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - George Shiyao He
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jolene Li Ling Chia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Gladys Qiao Xuan Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yao Neng Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yao Hao Teo
- Department of Medicine, National University Hospital, Singapore, Singapore
| | - Nicholas L Syn
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ping Chai
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore
| | - Raymond C C Wong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore
| | - Tiong-Cheng Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore
| | - William K F Kong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore
| | - Kian-Keong Poh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore.
| |
Collapse
|
2
|
Kemi Y, Yamashita E, Kario K, Kinoshita S, Sugano K, Yano H, Kuribara J, Kawaguchi R, Naito S. Clinical Impact of Preoperative Symptoms of Aortic Stenosis on Prognosis After Transcatheter Aortic Valve Replacement. Circ Rep 2024; 6:223-229. [PMID: 38860183 PMCID: PMC11162866 DOI: 10.1253/circrep.cr-24-0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/10/2024] [Accepted: 04/24/2024] [Indexed: 06/12/2024] Open
Abstract
Background: The prognostic significance of different presentations of aortic stenosis (AS) remains unclear. Our aim was to analyze outcomes after transcatheter aortic valve replacement (TAVR) according to preoperative AS symptoms. Methods and Results: We retrospectively enrolled 369 consecutive patients (age 84.3±5.0 years, and 64% females) who underwent TAVR from 2014 to 2021. We divided them into 4 groups by the main preoperative symptom: asymptomatic (n=50), chest pain (n=46), heart failure (HF; n=240), and syncope (n=33). Post-TAVR rates of HF readmission, all-cause death and cardiac death were compared among the 4 groups. The 4 groups showed no significant trends in age, sex, stroke volume index, or echocardiography indices of AS severity. During a follow-up, the overall survival rate at 1 and 5 years after TAVR was 97% and 90% in the asymptomatic group, 96% and 69% in the chest pain group, 93% and 69% in the HF group, and 90% and 72% in the syncope group, respectively. HF and syncope symptom had significantly lower HF readmission or cardiac death-free survival at 5 years after TAVR (log-rank test P=0.038). In the Cox hazard multivariate analysis, preoperative syncope was an independent predictor of future HF readmission or cardiac death after TAVR (HR=9.87; 95% CI 1.67-97.2; P=0.035). Conclusions: AS patients with preoperative syncope or HF had worse outcomes after TAVR than those with angina or no symptoms.
Collapse
Affiliation(s)
- Yuta Kemi
- Division of Cardiology, Gunma Prefectural Cardiovascular Center Maebashi Japan
- Division of Cardiology, Jichi Medical University School of Medicine Shimotsuke Japan
| | - Eiji Yamashita
- Division of Cardiology, Gunma Prefectural Cardiovascular Center Maebashi Japan
- Division of Cardiology, Jichi Medical University School of Medicine Shimotsuke Japan
| | - Kazuomi Kario
- Division of Cardiology, Jichi Medical University School of Medicine Shimotsuke Japan
| | - Satoshi Kinoshita
- Division of Cardiology, Gunma Prefectural Cardiovascular Center Maebashi Japan
| | - Kouta Sugano
- Division of Cardiology, Gunma Prefectural Cardiovascular Center Maebashi Japan
| | - Hideki Yano
- Division of Cardiology, Gunma Prefectural Cardiovascular Center Maebashi Japan
| | - Jun Kuribara
- Division of Cardiology, Gunma Prefectural Cardiovascular Center Maebashi Japan
| | - Ren Kawaguchi
- Division of Cardiology, Gunma Prefectural Cardiovascular Center Maebashi Japan
| | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center Maebashi Japan
| |
Collapse
|
3
|
Velders BJJ, Groenwold RHH, Ajmone Marsan N, Kappetein AP, Wijngaarden RAFDLV, Braun J, Klautz RJM, Vriesendorp MD. Improving accuracy in diagnosing aortic stenosis severity: An in-depth analysis of echocardiographic measurement error through literature review and simulation study. Echocardiography 2023; 40:892-902. [PMID: 37519290 DOI: 10.1111/echo.15664] [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: 04/26/2023] [Revised: 07/10/2023] [Accepted: 07/23/2023] [Indexed: 08/01/2023] Open
Abstract
AIMS The present guidelines advise replacing the aortic valve for individuals with severe aortic stenosis (AS) based on various echocardiographic parameters. Accurate measurements are essential to avoid misclassification and unnecessary interventions. The objective of this study was to evaluate the influence of measurement error on the echocardiographic evaluation of the severity of AS. METHODS AND RESULTS A systematic review was performed to examine whether measurement errors are reported in studies focusing on the prognostic value of peak aortic jet velocity (Vmax ), mean pressure gradient (MPG), and effective orifice area (EOA) in asymptomatic patients with AS. Out of the 37 studies reviewed, 17 (46%) acknowledged the existence of measurement errors, but none of them utilized methods to address them. Secondly, the magnitude of potential errors was collected from available literature for use in clinical simulations. Interobserver variability ranged between 0.9% and 8.3% for Vmax and MPG but was higher for EOA (range 7.7%-12.7%), indicating lower reliability. Assuming a circular left ventricular outflow tract area led to a median underestimation of EOA by 23% compared to planimetry by other modalities. A clinical simulation resulted in the reclassification of 42% of patients, shifting them from a diagnosis of severe AS to moderate AS. CONCLUSIONS Measurement errors are underreported in studies on echocardiographic assessment of AS severity. These errors can lead to misclassification and misdiagnosis. Clinicians and scientists should be aware of the implications for accurate clinical decision-making and assuring research validity.
Collapse
Affiliation(s)
- Bart J J Velders
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Biomedical Data Science, Leiden University Medical Center, Leiden, The Netherlands
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Arie-Pieter Kappetein
- Global Clinical Operations, Coronary and Structural Heart, Medtronic, Maastricht, The Netherlands
| | | | - Jerry Braun
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Robert J M Klautz
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Michiel D Vriesendorp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|
4
|
A novel cardiovascular magnetic resonance risk score for predicting mortality following surgical aortic valve replacement. Sci Rep 2021; 11:20183. [PMID: 34642428 PMCID: PMC8511276 DOI: 10.1038/s41598-021-99788-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 09/15/2021] [Indexed: 12/23/2022] Open
Abstract
The increasing prevalence of patients with aortic stenosis worldwide highlights a clinical need for improved and accurate prediction of clinical outcomes following surgery. We investigated patient demographic and cardiovascular magnetic resonance (CMR) characteristics to formulate a dedicated risk score estimating long-term survival following surgery. We recruited consecutive patients undergoing CMR with gadolinium administration prior to surgical aortic valve replacement from 2003 to 2016 in two UK centres. The outcome was overall mortality. A total of 250 patients were included (68 ± 12 years, male 185 (60%), with pre-operative mean aortic valve area 0.93 ± 0.32cm2, LVEF 62 ± 17%) and followed for 6.0 ± 3.3 years. Sixty-one deaths occurred, with 10-year mortality of 23.6%. Multivariable analysis showed that increasing age (HR 1.04, P = 0.005), use of antiplatelet therapy (HR 0.54, P = 0.027), presence of infarction or midwall late gadolinium enhancement (HR 1.52 and HR 2.14 respectively, combined P = 0.12), higher indexed left ventricular stroke volume (HR 0.98, P = 0.043) and higher left atrial ejection fraction (HR 0.98, P = 0.083) associated with mortality and developed a risk score with good discrimination. This is the first dedicated risk prediction score for patients with aortic stenosis undergoing surgical aortic valve replacement providing an individualised estimate for overall mortality. This model can help clinicians individualising medical and surgical care. Trial Registration ClinicalTrials.gov Identifier: NCT00930735 and ClinicalTrials.gov Identifier: NCT01755936.
Collapse
|
5
|
Symptomatic paradoxical low gradient severe aortic stenosis: A possible link to heart failure with preserved ejection fraction. J Cardiol 2019; 73:536-543. [DOI: 10.1016/j.jjcc.2018.12.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 12/14/2018] [Accepted: 12/18/2018] [Indexed: 01/06/2023]
|
6
|
González Saldivar H, Vicent Alaminos L, Rodríguez-Pascual C, de la Morena G, Fernández-Golfín C, Amorós C, Baquero Alonso M, Martínez Dolz L, Ariza Solé A, Guzmán-Martínez G, Gómez-Doblas JJ, Arribas Jiménez A, Fuentes ME, Galian Gay L, Ruiz Ortiz M, Avanzas P, Abu-Assi E, Ripoll-Vera T, Díaz-Castro O, Pozo Osinalde E, Bernal E, Martínez-Sellés M. Evolución de los pacientes con estenosis aórtica grave tras la indicación de intervención. Rev Esp Cardiol 2019. [DOI: 10.1016/j.recesp.2018.02.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
7
|
González Saldivar H, Vicent Alaminos L, Rodríguez-Pascual C, de la Morena G, Fernández-Golfín C, Amorós C, Baquero Alonso M, Martínez Dolz L, Ariza Solé A, Guzmán-Martínez G, Gómez-Doblas JJ, Arribas Jiménez A, Fuentes ME, Galian Gay L, Ruiz Ortiz M, Avanzas P, Abu-Assi E, Ripoll-Vera T, Díaz-Castro O, Pozo Osinalde E, Bernal E, Martínez-Sellés M. Prognosis of Patients With Severe Aortic Stenosis After the Decision to Perform an Intervention. ACTA ACUST UNITED AC 2018; 72:392-397. [PMID: 29997054 DOI: 10.1016/j.rec.2018.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 03/02/2018] [Indexed: 11/27/2022]
Abstract
INTRODUCTION AND OBJECTIVES Current therapeutic options for severe aortic stenosis (AS) include transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). Our aim was to describe the prognosis of patients with severe AS after the decision to perform an intervention, to study the variables influencing their prognosis, and to describe the determinants of waiting time > 2 months. METHODS Subanalysis of the IDEAS (Influence of the Severe Aortic Stenosis Diagnosis) registry in patients indicated for TAVI or SAVR. RESULTS Of 726 patients with severe AS diagnosed in January 2014, the decision to perform an intervention was made in 300, who were included in the present study. The mean age was 74.0 ± 9.7 years. A total of 258 (86.0%) underwent an intervention: 59 TAVI and 199 SAVR. At the end of the year, 42 patients (14.0%) with an indication for an intervention did not receive it, either because they remained on the waiting list (34 patients) or died while waiting for the procedure (8 patients). Of the patients who died while on the waiting list, half did so in the first 100 days. The mean waiting time was 2.9 ± 1.6 for TAVI and 3.5 ± 0.2 months for SAVR (P = .03). The independent predictors of mortality were male sex (HR, 2.6; 95%CI, 1.1-6.0), moderate-severe mitral regurgitation (HR, 2.6; 95%CI, 1.5-4.5), reduced mobility (HR, 4.6; 95%CI, 1.7-12.6), and nonintervention (HR, 2.3; 95%CI, 1.02-5.03). CONCLUSIONS Patients with severe aortic stenosis awaiting therapeutic procedures have a high mortality risk. Some clinical indicators predict a worse prognosis and suggest the need for early intervention.
Collapse
Affiliation(s)
- Hugo González Saldivar
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Lourdes Vicent Alaminos
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | | | - Gonzalo de la Morena
- Unidad de Imagen, Servicio de Cardiología, Instituto Murciano de Investigación Biosanitaria Virgen de la Arrixaca (IMIB), Hospital Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | | | - Carmen Amorós
- Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Luis Martínez Dolz
- Servicio de Cardiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Albert Ariza Solé
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Gabriela Guzmán-Martínez
- Servicio de Cardiología, Hospital Universitario La Paz, Instituto de Investigación Hospital Universitario La Paz (IdIPaz), Madrid, Spain
| | | | | | | | - Laura Galian Gay
- Servicio de Cardiología, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Martín Ruiz Ortiz
- Servicio de Cardiología, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Pablo Avanzas
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Emad Abu-Assi
- Servicio de Cardiología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Tomás Ripoll-Vera
- Servicio de Cardiología, Hospital Son Llàtzer, Instituto de Investigación Sanitaria de Palma (Idispa), Palma de Mallorca, Balearic Islands, Spain
| | - Oscar Díaz-Castro
- Servicio de Cardiología, Hospital de Pontevedra, Vigo, Pontevedra, Spain
| | | | - Eva Bernal
- Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain; Universidad Europea, Universidad Complutense, Madrid, Spain.
| |
Collapse
|
8
|
Cost effectiveness of transcatheter aortic valve implantation in patients with aortic stenosis in Japan. J Cardiol 2017; 71:223-229. [PMID: 29153740 DOI: 10.1016/j.jjcc.2017.10.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 09/26/2017] [Accepted: 10/10/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Transcatheter aortic valve implantation (TAVI) is a less invasive treatment for elderly patients with aortic stenosis. However, the cost of TAVI is a major issue. This study analyzed the cost effectiveness of TAVI in Japan. METHODS We developed an economic model to evaluate the quality-adjusted life years (QALYs) and costs of TAVI, surgical aortic valve replacement (SAVR), and medical therapy over a 10-year time horizon from the perspective of Japanese public healthcare payers. The first model compared transapical or transfemoral TAVI with Sapien valve implantation and medical therapy in inoperable patients. The second model compared transfemoral TAVI with Sapien XT valve implantation and SAVR in operable patients with intermediate surgical risk. We assumed a cost-effectiveness threshold of 5,000,000yen per QALY, and assessed the cost-effectiveness probability with 100,000 simulations. We performed a broad sensitivity analysis to assess the effect of uncertainty on our results. RESULTS Among inoperable patients, the incremental cost-effectiveness ratio for TAVI compared with medical therapy was 3,918,808yen per QALY. In operable patients, the incremental cost-effectiveness ratio for TAVI compared with SAVR was 7,523,821yen per QALY. The cost-effectiveness probability of TAVI was 60% for inoperable patients and 46% for operable patients. Among inoperable patients, the cost-effective threshold of TAVI was <7,759,085yen. Among operable patients, the cost-effective threshold of TAVI was <5,427,439yen. CONCLUSIONS This study suggests that TAVI has good cost effectiveness for inoperable patients, but not for operable patients.
Collapse
|
9
|
Klaeboe LG, Haland TF, Leren IS, ter Bekke RM, Brekke PH, Røsjø H, Omland T, Gullestad L, Aakhus S, Haugaa KH, Edvardsen T. Prognostic Value of Left Ventricular Deformation Parameters in Patients with Severe Aortic Stenosis: A Pilot Study of the Usefulness of Strain Echocardiography. J Am Soc Echocardiogr 2017; 30:727-735.e1. [DOI: 10.1016/j.echo.2017.04.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Indexed: 12/15/2022]
|