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Alsidawi S, Khan S, Pislaru SV, Thaden JJ, El-Am EA, Scott CG, Morant K, Oguz D, Luis SA, Padang R, Lane CE, McCully RB, Pellikka PA, Oh JK, Nkomo VT. High Prevalence of Severe Aortic Stenosis in Low-Flow State Associated With Atrial Fibrillation. Circ Cardiovasc Imaging 2021; 14:e012453. [PMID: 34250815 DOI: 10.1161/circimaging.120.012453] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a low-flow state and may underestimate aortic stenosis (AS) severity. Single-high Doppler signals (HS) consistent with severe AS (peak velocity ≥4 m/s or mean gradient ≥40 mm Hg) are averaged down in current practice. The objective for the study was to determine the significance of HS in AF low-gradient AS (LGAS). METHODS One thousand five hundred forty-one patients with aortic valve area ≤1 cm2 and left ventricular ejection fraction ≥50% were identified and classified as high-gradient AS (HGAS) (≥40 mm Hg) and LGAS (<40 mm Hg), and AF versus sinus rhythm (SR). Available computed tomography aortic valve calcium scores (AVCS) were retrieved from the medical record. Outcomes were assessed. RESULTS Mean age was 76±11 years, female 47%. Mean gradient was 51±12 in SR-HGAS, 48±10 in AF-HGAS, 31±5 in SR-LGAS, and 29±7 mm Hg in AF-LGAS, all P≤0.001 versus SR-HGAS; HS were present in 33% of AF-LGAS. AVCS were available in 34%. Compared with SR-HGAS (2409 arbitrary units; interquartile range, 1581-3462) AVCS were higher in AF-HGAS (2991 arbitrary units; IQR1978-4229, P=0.001), not different in AF-LGAS (2399 arbitrary units; IQR1817-2810, P=0.47), and lower in SR-LGAS (1593 arbitrary units; IQR945-1832, P<0.001); AVCS in AF-LGAS were higher when HS were present (P=0.048). Compared with SR-HGAS, the age-, sex-, comorbidity index-, and time-dependent aortic valve replacement-adjusted mortality risk was higher in AF-HGAS (hazard ratio=1.82 [1.40-2.36], P<0.001) and AF-LGAS with HS (hazard ratio=1.54 [1.04-2.26], P=0.03) but not different in AF-LGAS without HS or SR-LGAS (both P=not significant). CONCLUSIONS Severe AS was common in AF-LGAS. AVCS in AF-LGAS were not different from SR-HGAS. AVCS were higher and mortality worse in AF-LGAS when HS were present.
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Affiliation(s)
- Said Alsidawi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.).,Minneapolis Heart Institute, Minneapolis, MN (S.A.)
| | - Sana Khan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.).,University of Minnesota, Minneapolis, MN (S.K.)
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Edward A El-Am
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.).,Department of Medicine, Indiana University School of Medicine, Indianapolis (E.A.E.-A.)
| | | | - Kareem Morant
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.).,North York General Hospital, Toronto, ON, Canada (K.M.)
| | - Didem Oguz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Sushil A Luis
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Colleen E Lane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Robert B McCully
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Patricia A Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
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Altes A, Thellier N, Bohbot Y, Marsou W, Chadha G, Binda C, Ringle A, Mailliet A, Marotte N, Riolet C, Tribouilloy C, Maréchaux S. Prognostic Impact of the Ratio of Acceleration Time to Ejection Time in Patients With Low Gradient Severe Aortic Stenosis and Preserved Ejection Fraction. Am J Cardiol 2019; 124:1594-1600. [PMID: 31522771 DOI: 10.1016/j.amjcard.2019.07.064] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 07/30/2019] [Accepted: 07/31/2019] [Indexed: 11/17/2022]
Abstract
The clinical management of patients with low gradient severe aortic stenosis (LG-SAS) and preserved left ventricular ejection fraction (LVEF) remains challenging owing to their heterogeneity. The aim to this study was to evaluate the relation between an ejection dynamic parameter linked to AS severity and outcome, the ratio of acceleration time (AT) to ejection time (ET), in a cohort of patients with LG-SAS and preserved LVEF. Three hundred and fifty-six patients with LG-AS (defined by AVA ≤1 cm² and/or AVAi ≤0.6 cm²/m² and mean aortic pressure gradient <40 mm Hg) and preserved LVEF ≥50% were studied. The relation between AT/ET and all-cause and cardiac mortality during follow-up was studied. Median follow-up was 41 months (interquartile range, 35 to 47 months). Median AT/ET was 0.32 (interquartile range, 0.29 to 0.36). The 5-year estimates of all-cause and cardiac mortality were respectively 57 ± 7%, 36 ± 7% for patients with AT/ET >0.36 versus 43 ± 4%, 16 ± 3% for patients with AT/ET ≤0.36 (p = 0.024 and p <0.001, respectively). After adjustment on known predictors of outcome including aortic valve replacement used as a time-dependent covariate, there was a significant increase in all-cause mortality risk for patients with AT/ET >0.36 (adjusted hazard ratio 2.04 [95% confidence interval, 1.32 to 3.13]; p = 0.001) and cardiac mortality risk (adjusted hazard ratio 2.89 [95% confidence interval, 1.54 to 5.43]; p<0.001) compared with patients with AT/ET ≤0.36. The association of AT/ET >0.36 and all-cause or cardiac mortality risk was consistent in subgroups of patients with LG-SAS and preserved EF. In conclusion, an AT/ET ratio of more than 0.36 is an independent predictor of mortality in patients with LG-SAS and preserved EF.
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Affiliation(s)
- Alexandre Altes
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France
| | - Nicolas Thellier
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France; Laboratoire UPJCV, Université de Picardie, Amiens, France
| | - Yohann Bohbot
- Centre Hospitalier Universitaire d'Amiens, Amiens, France; Laboratoire UPJCV, Université de Picardie, Amiens, France
| | - Wassima Marsou
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France
| | | | - Camille Binda
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France
| | - Anne Ringle
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France
| | - Amandine Mailliet
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France
| | - Nathalie Marotte
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France
| | - Clemence Riolet
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France
| | - Christophe Tribouilloy
- Centre Hospitalier Universitaire d'Amiens, Amiens, France; Laboratoire UPJCV, Université de Picardie, Amiens, France
| | - Sylvestre Maréchaux
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France; Laboratoire UPJCV, Université de Picardie, Amiens, France.
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