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González-García A, Pazos-López P, Calvo-Iglesias FE, Matajira-Chía TM, Bilbao-Quesada R, Blanco-González E, González-Ríos C, Castiñeira-Busto M, Barreiro-Pérez M, Íñiguez-Romo A. Diagnostic Challenges in Aortic Stenosis. J Cardiovasc Dev Dis 2024; 11:162. [PMID: 38921662 PMCID: PMC11203729 DOI: 10.3390/jcdd11060162] [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: 03/30/2024] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 06/27/2024] Open
Abstract
Aortic stenosis (AS) is the most prevalent degenerative valvular disease in western countries. Transthoracic echocardiography (TTE) is considered, nowadays, to be the main imaging technique for the work-up of AS due to high availability, safety, low cost, and excellent capacity to evaluate aortic valve (AV) morphology and function. Despite the diagnosis of AS being considered straightforward for a very long time, based on high gradients and reduced aortic valve area (AVA), many patients with AS represent a real dilemma for cardiologist. On the one hand, the acoustic window may be inadequate and the TTE limited in some cases. On the other hand, a growing body of evidence shows that patients with low gradients (due to systolic dysfunction, concentric hypertrophy or coexistence of another valve disease such as mitral stenosis or regurgitation) may develop severe AS (low-flow low-gradient severe AS) with a similar or even worse prognosis. The use of complementary imaging techniques such as transesophageal echocardiography (TEE), multidetector computed tomography (MDTC), or cardiac magnetic resonance (CMR) plays a key role in such scenarios. The aim of this review is to summarize the diagnostic challenges associated with patients with AS and the advantages of a comprehensive multimodality cardiac imaging (MCI) approach to reach a precise grading of the disease, a crucial factor to warrant an adequate management of patients.
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Affiliation(s)
- André González-García
- Department of Cardiology, Hospital Alvaro Cunqueiro, Complexo Hospitalario Universitario de Vigo, 36312 Vigo, Spain; (F.E.C.-I.); (T.M.M.-C.); (R.B.-Q.); (E.B.-G.); (C.G.-R.); (M.C.-B.); (M.B.-P.); (A.Í.-R.)
| | - Pablo Pazos-López
- Department of Cardiology, Hospital Alvaro Cunqueiro, Complexo Hospitalario Universitario de Vigo, 36312 Vigo, Spain; (F.E.C.-I.); (T.M.M.-C.); (R.B.-Q.); (E.B.-G.); (C.G.-R.); (M.C.-B.); (M.B.-P.); (A.Í.-R.)
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2
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Elkaryoni A, Huded CP, Saad M, Altibi AM, Chhatriwalla AK, Abbott JD, Arnold SV. Normal-Flow Low-Gradient Aortic Stenosis: Comparing the U.S. and European Guidelines. JACC Cardiovasc Imaging 2024:S1936-878X(24)00118-9. [PMID: 38703172 DOI: 10.1016/j.jcmg.2024.03.005] [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] [Received: 12/14/2023] [Revised: 02/12/2024] [Accepted: 03/06/2024] [Indexed: 05/06/2024]
Abstract
Patients with normal-flow low-gradient (NFLG) severe aortic stenosis present both diagnostic and management challenges, with debate about the whether this represents true severe stenosis and the need for valve replacement. Studies exploring the natural history without intervention have shown similar outcomes of patients with NFLG severe aortic stenosis to those with moderate aortic stenosis and better outcomes after valve replacement than those with low-flow low-gradient severe aortic stenosis. Most studies (all observational) have shown that aortic valve replacement was associated with a survival benefit vs surveillance. Based on available data, the European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines and European Association of Cardiovascular Imaging/American Society of Echocardiography suggest that these patients are more likely to have moderate aortic stenosis. This clinical entity is not mentioned in the American Heart Association/American College of Cardiology guidelines. Here we review the definition of NFLG severe aortic stenosis, potential diagnostic algorithms and points of error, the data supporting different management strategies, and the differing guidelines and outline the unanswered questions in the diagnosis and management of these challenging patients.
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Affiliation(s)
- Ahmed Elkaryoni
- Division of Cardiology, Warren Alpert Medical School of Brown University, Lifespan Cardiovascular Institute, Providence, Rhode Island, USA.
| | - Chetan P Huded
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Marwan Saad
- Division of Cardiology, Warren Alpert Medical School of Brown University, Lifespan Cardiovascular Institute, Providence, Rhode Island, USA
| | - Ahmed M Altibi
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Adnan K Chhatriwalla
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - J Dawn Abbott
- Division of Cardiology, Warren Alpert Medical School of Brown University, Lifespan Cardiovascular Institute, Providence, Rhode Island, USA
| | - Suzanne V Arnold
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
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3
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Kim K, Cho I, Ko KY, Lee SH, Lee S, Hong GR, Ha JW, Shim CY. Early Aortic Valve Replacement in Symptomatic Normal-Flow, Low-Gradient Severe Aortic Stenosis: A Propensity Score-Matched Retrospective Cohort Study. Korean Circ J 2023; 53:744-755. [PMID: 37653715 PMCID: PMC10654414 DOI: 10.4070/kcj.2023.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/16/2023] [Accepted: 06/18/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Aortic valve replacement (AVR) is considered a class I indication for symptomatic severe aortic stenosis (AS). However, there is little evidence regarding the potential benefits of early AVR in symptomatic patients diagnosed with normal-flow, low-gradient (NFLG) severe AS. METHODS Two-hundred eighty-one patients diagnosed with symptomatic NFLG severe AS (stroke volume index ≥35 mL/m², mean transaortic pressure gradient <40 mmHg, peak transaortic velocity <4 m/s, and aortic valve area <1.0 cm²) between January 2010 and December 2020 were included in this retrospective study. After performing 1:1 propensity score matching, 121 patients aged 75.1±9.8 years (including 63 women) who underwent early AVR within 3 months after index echocardiography, were compared with 121 patients who received conservative care. The primary outcome was a composite of all-cause death and heart failure (HF) hospitalization. RESULTS During a median follow-up of 21.9 months, 48 primary outcomes (18 in the early AVR group and 30 in the conservative care group) occurred. The early AVR group demonstrated a significantly lower incidence of primary outcomes (hazard ratio [HR], 0.52; 95% confidence interval [CI], 0.29-0.93; p=0.028); specifically, there was no significant difference in all-cause death (HR, 0.51; 95% CI, 0.23-1.16; p=0.110), although the early AVR group showed a significantly lower incidence of hospitalization for HF (HR, 0.43; 95% CI, 0.19-0.95, p=0.037). Subgroup analyses supported the main findings. CONCLUSIONS An early AVR strategy may be beneficial in reducing the risk of a composite outcome of death or hospitalization for HF in symptomatic patients with NFLG severe AS. Future randomized studies are required to validate and confirm our findings.
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Affiliation(s)
- Kyu Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Iksung Cho
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kyu-Yong Ko
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung-Hyun Lee
- Department of Cardiothoracic Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sak Lee
- Department of Cardiothoracic Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Geu-Ru Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jong-Won Ha
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Chi Young Shim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
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4
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Okumus N, Abraham S, Puri R, Tang WHW. Aortic Valve Disease, Transcatheter Aortic Valve Replacement, and the Heart Failure Patient: A State-of-the-Art Review. JACC. HEART FAILURE 2023; 11:1070-1083. [PMID: 37611989 DOI: 10.1016/j.jchf.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 06/27/2023] [Accepted: 07/05/2023] [Indexed: 08/25/2023]
Abstract
Concomitant aortic stenosis (AS) in heart failure (HF) is associated with high rates of mortality and morbidity. Current guidelines recommend aortic valve replacement in patients with severe symptomatic AS and asymptomatic AS with left ventricular ejection fraction <50% and during other cardiac surgeries. Transcatheter aortic valve replacement (TAVR) has now allowed for the treatment of severe AS in previously inoperable or high-surgical-risk patients. Leveraging multimodality imaging techniques is increasingly recognized for reinforcing the rationale for intervening early, thus mitigating the risk of ongoing progression to advanced HF. There are increasing data in favor of TAVR in diverse clinical scenarios, particularly asymptomatic AS and moderate AS. Limited information is, however, available regarding the advantages of HF medical therapy before and after intervention. This review aims to comprehensively examine the phenotypes of AS in the context of HF progression, while exploring the evolving role of TAVR in specific populations.
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Affiliation(s)
- Nazli Okumus
- Allegheny General Hospital Cardiovascular Institute, Pittsburgh, Pennsylvania, USA
| | - Sonu Abraham
- Division of Cardiovascular Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Rishi Puri
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA.
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5
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Pestiaux C, Pyka G, Quirynen L, De Azevedo D, Vanoverschelde JL, Lengelé B, Vancraeynest D, Beauloye C, Kerckhofs G. 3D histopathology of stenotic aortic valve cusps using ex vivo microfocus computed tomography. Front Cardiovasc Med 2023; 10:1129990. [PMID: 37180789 PMCID: PMC10167041 DOI: 10.3389/fcvm.2023.1129990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 04/03/2023] [Indexed: 05/16/2023] Open
Abstract
Background Calcific aortic stenosis (AS) is the most prevalent heart valve disease in developed countries. The aortic valve cusps progressively thicken and the valve does not open fully due to the presence of calcifications. In vivo imaging, usually used for diagnosis, does not allow the visualization of the microstructural changes associated with AS. Methods Ex vivo high-resolution microfocus computed tomography (microCT) was used to quantitatively describe the microstructure of calcified aortic valve cusps in full 3D. As case study in our work, this quantitative analysis was applied to normal-flow low-gradient severe AS (NF-LG-SAS), for which the medical prognostic is still highly debated in the current literature, and high-gradient severe AS (HG-SAS). Results The volume proportion of calcification, the size and number of calcified particles and their density composition was quantified. A new size-based classification considering small-sized particles that are not detected with in vivo imaging was defined for macro-, meso- and microscale calcifications. Volume and thickness of aortic valve cusps, including the complete thickness distribution, were also determined. Moreover, changes in the cusp soft tissues were also visualized with microCT and confirmed by scanning electron microscopy images of the same sample. NF-LG-SAS cusps contained lower relative amount of calcifications than HG-SAS. Moreover, the number and size of calcified objects and the volume and thickness of the cusps were also lower in NF-LG-SAS cusps than in HG-SAS. Conclusions The application of high-resolution ex vivo microCT to stenotic aortic valve cusps provided a quantitative description of the general structure of the cusps and of the calcifications present in the cusp soft tissues. This detailed description could help in the future to better understand the mechanisms of AS.
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Affiliation(s)
- Camille Pestiaux
- Mechatronic, Electrical Energy and Dynamic Systems, Institute of Mechanics, Materials and Civil Engineering, UCLouvain, Louvain-la-Neuve, Belgium
- Pole of Morphology, Institute of Experimental and Clinical Research, UCLouvain, Brussels, Belgium
| | - Grzegorz Pyka
- Mechatronic, Electrical Energy and Dynamic Systems, Institute of Mechanics, Materials and Civil Engineering, UCLouvain, Louvain-la-Neuve, Belgium
- Pole of Morphology, Institute of Experimental and Clinical Research, UCLouvain, Brussels, Belgium
| | - Louise Quirynen
- Mechatronic, Electrical Energy and Dynamic Systems, Institute of Mechanics, Materials and Civil Engineering, UCLouvain, Louvain-la-Neuve, Belgium
| | - David De Azevedo
- Pole of Cardiovascular Research, Institute of Experimental and Clinical Research, UCLouvain, Brussels, Belgium
- Division of Cardiology, University Hospital Saint-Luc, Brussels, Belgium
| | - Jean-Louis Vanoverschelde
- Pole of Cardiovascular Research, Institute of Experimental and Clinical Research, UCLouvain, Brussels, Belgium
- Division of Cardiology, University Hospital Saint-Luc, Brussels, Belgium
| | - Benoît Lengelé
- Pole of Morphology, Institute of Experimental and Clinical Research, UCLouvain, Brussels, Belgium
| | - David Vancraeynest
- Pole of Cardiovascular Research, Institute of Experimental and Clinical Research, UCLouvain, Brussels, Belgium
- Division of Cardiology, University Hospital Saint-Luc, Brussels, Belgium
| | - Christophe Beauloye
- Pole of Cardiovascular Research, Institute of Experimental and Clinical Research, UCLouvain, Brussels, Belgium
- Division of Cardiology, University Hospital Saint-Luc, Brussels, Belgium
| | - Greet Kerckhofs
- Mechatronic, Electrical Energy and Dynamic Systems, Institute of Mechanics, Materials and Civil Engineering, UCLouvain, Louvain-la-Neuve, Belgium
- Pole of Morphology, Institute of Experimental and Clinical Research, UCLouvain, Brussels, Belgium
- Department of Materials Engineering, KU Leuven, Heverlee, Belgium
- Prometheus, Division for Skeletal Tissue Engineering, KU Leuven, Leuven, Belgium
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6
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Sharma N, Sachedina AK, Kumar S. Low-flow, Low-gradient Severe Aortic Stenosis: A Review. Heart Int 2023; 17:8-12. [PMID: 37456345 PMCID: PMC10339455 DOI: 10.17925/hi.2023.17.1.8] [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: 10/31/2022] [Accepted: 11/25/2022] [Indexed: 07/18/2023] Open
Abstract
Aortic stenosis (AS) is a common valve pathology experienced by patients worldwide. There are limited population-based studies assessing its prevalence; however, epidemiological studies emphasize that the burden of disease is growing. Recognizing AS relies on accurate clinical assessment and diagnostic investigations. Patients who develop severe AS are often referred to the heart team for assessment of aortic valve intervention. Although echocardiography has traditionally been used to screen and monitor the progression of AS, there can be discordance between measurements in a low-flow state. Such patients may have truly severe AS and potentially derive long-term benefit from aortic valve intervention. Accurately identifying these patients with the use of ancillary testing has been the focus of research for several years. In this article, we discuss the contemporary approaches and challenges in identifying and managing patients with low-flow, low-gradient severe AS.
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Affiliation(s)
- Nishant Sharma
- Libin Cardiovascular Institute, Foothills Medical Centre, University of Calgary, Calgary, Canada
| | - Ayaaz K Sachedina
- Libin Cardiovascular Institute, Foothills Medical Centre, University of Calgary, Calgary, Canada
| | - Sachin Kumar
- Memorial Hermann-Texas Medical Center, University of Texas Health Science Center, Houston, TX, USA
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7
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Normal flow low gradient aortic stenosis, is it truly a severe aortic stenosis that merits TAVI? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 39:18-19. [DOI: 10.1016/j.carrev.2022.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 03/22/2022] [Indexed: 11/17/2022]
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8
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Baljepally R, Tahir H, Goodwin RP, Livesay J, Fogelson B, Patel C, Coombes T, Wadi G, Dieter R. Comparison of transcatheter aortic valve implantation outcomes between normal flow low gradient severe aortic stenosis and normal flow high gradient severe aortic stenosis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 39:12-17. [PMID: 34764031 DOI: 10.1016/j.carrev.2021.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/08/2021] [Accepted: 10/29/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Normal flow low gradient severe aortic stenosis (NFLG-AS) with preserved ejection fraction is the most prevalent form of low gradient severe aortic stenosis. Despite the increased prevalence, the clinical outcomes and management strategy of NFLG-AS remain controversial. Therefore, our study aimed to evaluate transcatheter aortic valve implantation (TAVI) outcomes of patients with NFLG-AS compared with normal flow high gradient severe aortic stenosis (NFHG-AS). METHODS We performed a retrospective analysis of 394 patients who underwent TAVI between January 2011 to September 2020. Among 394 patients, 232 patients had NFLG-AS, and 162 patients had NFHG-AS. The primary outcomes included all-cause mortality and cardiovascular mortality. In addition, multiple secondary outcomes were evaluated, including stroke, myocardial infarction, duration of hospital stay, new-onset atrial fibrillation, temporary or permanent pacemaker requirement, major bleeding, blood transfusion, vascular complications, acute kidney injury, hemodialysis requirement, symptom improvement, and repeat hospitalizations due to any cardiac disease. RESULTS The cumulative six months incidence of all-cause mortality and cardiovascular mortality were similar between and NFLG-AS and NFHG-AS (4.32% vs. 5.17%, P = 0.71 and 2.47% vs. 2.59%, P = 0.94 respectively). There was no difference in the rates of stroke, myocardial infarction, duration of hospital stay, new-onset atrial fibrillation, temporary or permanent pacemaker requirement, major bleeding, blood transfusion, vascular complications, acute kidney injury, hemodialysis requirement, and symptom improvement between the two groups. However, patients with NFLG-AS compared to NFHG-AS had more frequent cardiac-related repeat hospitalizations (19.14% vs. 11.64%, P = 0.04%). CONCLUSION There was no significant difference in all-cause mortality and cardiovascular mortality between NFLG-AS and NGHG-AS six months post-TAVI. However, patients undergoing TAVI with NFLG-AS had significantly higher rates of cardiac-related repeat hospitalizations.
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Affiliation(s)
- Raj Baljepally
- University of Tennessee Medical Center, Heart Lung Vascular Institute, Dept. of Cardiology, Knoxville, TN, United States of America
| | - Hassan Tahir
- University of Tennessee Medical Center, Heart Lung Vascular Institute, Dept. of Cardiology, Knoxville, TN, United States of America.
| | - Racheal P Goodwin
- University of Tennessee Medical Center, Heart Lung Vascular Institute, Dept. of Cardiology, Knoxville, TN, United States of America
| | - James Livesay
- University of Tennessee Medical Center, Heart Lung Vascular Institute, Dept. of Cardiology, Knoxville, TN, United States of America
| | - Benjamin Fogelson
- University of Tennessee Medical Center, Dept. of Internal Medicine, Knoxville, TN, United States of America
| | - Chirag Patel
- University of Tennessee Medical Center, Dept. of Internal Medicine, Knoxville, TN, United States of America
| | - Tyler Coombes
- University of Tennessee Medical Center, Dept. of Internal Medicine, Knoxville, TN, United States of America
| | - Ghassan Wadi
- University of Tennessee Medical Center, Dept. of Internal Medicine, Knoxville, TN, United States of America
| | - Raymond Dieter
- University of Tennessee Medical Center, Dept. of Cardiothoracic Surgery, Knoxville, TN, United States of America
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9
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Guzzetti E, Annabi MS, Pibarot P, Clavel MA. Multimodality Imaging for Discordant Low-Gradient Aortic Stenosis: Assessing the Valve and the Myocardium. Front Cardiovasc Med 2020; 7:570689. [PMID: 33344514 PMCID: PMC7744378 DOI: 10.3389/fcvm.2020.570689] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 10/12/2020] [Indexed: 01/29/2023] Open
Abstract
Aortic stenosis (AS) is a disease of the valve and the myocardium. A correct assessment of the valve disease severity is key to define the need for aortic valve replacement (AVR), but a better understanding of the myocardial consequences of the increased afterload is paramount to optimize the timing of the intervention. Transthoracic echocardiography remains the cornerstone of AS assessment, as it is universally available, and it allows a comprehensive structural and hemodynamic evaluation of both the aortic valve and the rest of the heart. However, it may not be sufficient as a significant proportion of patients with severe AS presents with discordant grading (i.e., an AVA ≤ 1 cm2 and a mean gradient <40 mmHg) which raises uncertainty about the true severity of AS and the need for AVR. Several imaging modalities (transesophageal or stress echocardiography, computed tomography, cardiovascular magnetic resonance, positron emission tomography) exist that allow a detailed assessment of the stenotic aortic valve and the myocardial remodeling response. This review aims to provide an updated overview of these multimodality imaging techniques and seeks to highlight a practical approach to help clinical decision making in the challenging group of patients with discordant low-gradient AS.
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Affiliation(s)
- Ezequiel Guzzetti
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Quebec, QC, Canada
| | - Mohamed-Salah Annabi
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Quebec, QC, Canada
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Quebec, QC, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Quebec, QC, Canada
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10
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Updates to a Modern Dilemma: a Practical Approach to the Workup and Management of Low-Gradient Severe Aortic Stenosis Using Transvalvular Flow Rate. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00865-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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11
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Salaun E, Clavel MA, Hahn RT, Jaber WA, Asch FM, Rodriguez L, Weissman NJ, Gertz ZM, Herrmann HC, Dahou A, Annabi MS, Toubal O, Bernier M, Beaudoin J, Leipsic J, Blanke P, Ridard C, Ong G, Rodés-Cabau J, Webb JG, Zhang Y, Alu MC, Douglas PS, Makkar R, Miller DC, Lindman BR, Thourani VH, Leon MB, Pibarot P. Outcome of Flow-Gradient Patterns of Aortic Stenosis After Aortic Valve Replacement. Circ Cardiovasc Interv 2020; 13:e008792. [DOI: 10.1161/circinterventions.119.008792] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Although aortic valve replacement is associated with a major benefit in high-gradient (HG) severe aortic stenosis (AS), the results in low-gradient (LG, mean gradient <40 mm Hg) AS are conflicting. LG severe AS may be subdivided in classical low-flow (left ventricular ejection fraction <50%) and LG (CLF-LG); paradoxical low-flow (left ventricular ejection fraction ≥50% but stroke volume index <35 mL/m
2
) and LG; and normal-flow (left ventricular ejection fraction ≥50% and stroke volume index ≥35 mL/m
2
) and LG. The primary objective is to determine in the PARTNER 2 trial (The Placement of Aortic Transcatheter Valves) and registry the outcomes after aortic valve replacement of the 4 flow-gradient groups.
Methods:
A total of 3511 patients from the PARTNER 2 Cohort A randomized trial (n=1910) and SAPIEN 3 registry (n=1601) were included. The flow-gradient pattern was determined at baseline transthoracic echocardiography and classified as follows: (1) HG; (2) CLF-LG; (3) paradoxical low-flow-LG; and (4) normal-flow-LG. The primary end point for this analysis was the composite of (1) death; (2) rehospitalization for heart failure symptoms and valve prosthesis complication; or (3) stroke.
Results:
The distribution was HG, 2229 patients (63.5%); CLF-LG, 689 patients (19.6%); paradoxical low-flow-LG, 247 patients (7.0%); and normal-flow-LG, 346 patients (9.9%). The 2-year rate of primary end point was higher in CLF-LG (38.8%) versus HG: 31.8% (
P
=0.002) and normal-flow-LG: 32.1% (
P
=0.05) but was not statistically different from paradoxical low-flow-LG: 33.6% (
P
=0.18). There was no significant difference in the 2-year rates of clinical events between transcatheter aortic valve replacement versus surgical aortic valve replacement in the whole cohort and within each flow-gradient group.
Conclusions:
The LG AS pattern was highly prevalent (36.5%) in the PARTNER 2 trial and registry. CLF-LG was the most common pattern of LG AS and was associated with higher rates of death, rehospitalization, or stroke at 2 years compared with the HG group. Clinical outcomes were as good in the LG AS groups with preserved left ventricular ejection fraction compared with the HG group.
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Affiliation(s)
- Erwan Salaun
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Canada (E.S., M.-A.C., A.D., M.-S.A., O.T., M.B., J.B., C.R., G.O., J.R.-C., P.P.)
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Canada (E.S., M.-A.C., A.D., M.-S.A., O.T., M.B., J.B., C.R., G.O., J.R.-C., P.P.)
| | - Rebecca T. Hahn
- Columbia University Medical Center/New York- Presbyterian Hospital (R.T.H., A.D., Y.Z., M.C.A., M.B.L.)
- Cardiovascular Research Foundation, New York, NY (R.T.H., Y.Z., M.C.A., M.B.L.)
| | - Wael A. Jaber
- Heart and Vascular Institute, Cleveland Clinic, OH (W.A.J., L.R.)
| | - Federico M. Asch
- MedStar Health Research Institute at Washington Hospital Center, DC (F.M.A., N.J.W., V.H.T.)
| | | | - Neil J. Weissman
- MedStar Health Research Institute at Washington Hospital Center, DC (F.M.A., N.J.W., V.H.T.)
| | - Zachary M. Gertz
- Division of Cardiology, Virginia Commonwealth University, Richmond (Z.M.G.)
| | | | - Abdellaziz Dahou
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Canada (E.S., M.-A.C., A.D., M.-S.A., O.T., M.B., J.B., C.R., G.O., J.R.-C., P.P.)
- Columbia University Medical Center/New York- Presbyterian Hospital (R.T.H., A.D., Y.Z., M.C.A., M.B.L.)
| | - Mohamed-Salah Annabi
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Canada (E.S., M.-A.C., A.D., M.-S.A., O.T., M.B., J.B., C.R., G.O., J.R.-C., P.P.)
| | - Oumhani Toubal
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Canada (E.S., M.-A.C., A.D., M.-S.A., O.T., M.B., J.B., C.R., G.O., J.R.-C., P.P.)
| | - Mathieu Bernier
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Canada (E.S., M.-A.C., A.D., M.-S.A., O.T., M.B., J.B., C.R., G.O., J.R.-C., P.P.)
| | - Jonathan Beaudoin
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Canada (E.S., M.-A.C., A.D., M.-S.A., O.T., M.B., J.B., C.R., G.O., J.R.-C., P.P.)
| | - Jonathon Leipsic
- St Paul’s Hospital, Vancouver, British Columbia, Canada (J.L., P.B., J.G.W.)
| | - Philipp Blanke
- St Paul’s Hospital, Vancouver, British Columbia, Canada (J.L., P.B., J.G.W.)
| | - Carine Ridard
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Canada (E.S., M.-A.C., A.D., M.-S.A., O.T., M.B., J.B., C.R., G.O., J.R.-C., P.P.)
| | - Géraldine Ong
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Canada (E.S., M.-A.C., A.D., M.-S.A., O.T., M.B., J.B., C.R., G.O., J.R.-C., P.P.)
- Division of Cardiology, St Michael’s Hospital, Toronto, ON, Canada (G.O.)
| | - Josep Rodés-Cabau
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Canada (E.S., M.-A.C., A.D., M.-S.A., O.T., M.B., J.B., C.R., G.O., J.R.-C., P.P.)
| | - John G. Webb
- St Paul’s Hospital, Vancouver, British Columbia, Canada (J.L., P.B., J.G.W.)
| | - Yiran Zhang
- Columbia University Medical Center/New York- Presbyterian Hospital (R.T.H., A.D., Y.Z., M.C.A., M.B.L.)
- Cardiovascular Research Foundation, New York, NY (R.T.H., Y.Z., M.C.A., M.B.L.)
| | - Maria C. Alu
- Columbia University Medical Center/New York- Presbyterian Hospital (R.T.H., A.D., Y.Z., M.C.A., M.B.L.)
- Cardiovascular Research Foundation, New York, NY (R.T.H., Y.Z., M.C.A., M.B.L.)
| | - Pamela S. Douglas
- Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (P.S.D.)
| | - Raj Makkar
- Cedars–Sinai Heart Institute, Los Angeles, CA (R.M.)
| | - D. Craig Miller
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, CA (D.C.M.)
| | | | - Vinod H. Thourani
- MedStar Health Research Institute at Washington Hospital Center, DC (F.M.A., N.J.W., V.H.T.)
| | - Martin B. Leon
- Columbia University Medical Center/New York- Presbyterian Hospital (R.T.H., A.D., Y.Z., M.C.A., M.B.L.)
- Cardiovascular Research Foundation, New York, NY (R.T.H., Y.Z., M.C.A., M.B.L.)
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Canada (E.S., M.-A.C., A.D., M.-S.A., O.T., M.B., J.B., C.R., G.O., J.R.-C., P.P.)
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12
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Chadha G, Bohbot Y, Rusinaru D, Maréchaux S, Tribouilloy C. Outcome of Normal-Flow Low-Gradient Severe Aortic Stenosis With Preserved Left Ventricular Ejection Fraction: A Propensity-Matched Study. J Am Heart Assoc 2019; 8:e012301. [PMID: 31550970 PMCID: PMC6806034 DOI: 10.1161/jaha.119.012301] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background Normal‐flow, low‐gradient severe aortic stenosis (NF‐LG‐SAS), defined by aortic valve area <1 cm2, mean gradient <40 mm Hg, and indexed stroke volume >35 mL/m2, is the most prevalent form of low‐gradient aortic stenosis (AS). However, the true severity of AS and the management of NF‐LG‐SAS are controversial. The aim of this study was to evaluate the outcome of patients with NF‐LG‐SAS compared with moderate AS (MAS) and with high‐gradient severe‐AS (HG‐SAS). Methods and Results A total of 154 patients with NF‐LG‐SAS, 366 with MAS (aortic valve area between 1.0 and 1.3 cm2), and 1055 with HG‐SAS were included. On multivariate analysis, after adjustment for covariates of prognostic importance, NF‐LG‐SAS patients did not exhibit an excess risk of mortality compared with MAS patients under medical management (hazard ratio=1.13 [95% CI, 0.82‐1.56]; P=0.45) and under medical and surgical management (hazard ratio 1.06 [95% CI, 0.79‐1.43]; P=0.70), even after further adjustment for aortic valve replacement (hazard ratio=1.09 [95% CI, 0.81‐1.48]; P=0.56). The 6‐year cumulative incidence of aortic valve replacement (performed in accordance with guidelines) was comparable between the 2 groups (39±4% for NF‐LG‐SAS and 35±3% for MAS, P=0.10). After propensity score matching (n=226), NF‐LG‐SAS and MAS patients also had comparable outcomes under medical (P=0.41) and under medical and surgical management (P=0.52). NF‐LG‐SAS had better outcomes than HG‐SAS patients (adjusted hazard ratio 1.84 [95% CI, 1.18‐2.88]; P<0.001). Conclusions This study shows that patients with NF‐LG‐SAS have a comparable outcome to those with MAS when aortic valve replacement is performed during follow‐up according to guidelines, mostly at the stage of HG‐SAS. Rigorous echocardiographic assessment to rule out measurement errors and close follow‐up are essential to detect progression to true severe AS in NF‐LG‐SAS.
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Affiliation(s)
- Gagandeep Chadha
- Department of Cardiology Amiens University Hospital Amiens France
| | - Yohann Bohbot
- Department of Cardiology Amiens University Hospital Amiens France.,EA 7517 MP3CV Jules Verne University of Picardie Amiens France
| | - Dan Rusinaru
- Department of Cardiology Amiens University Hospital Amiens France.,EA 7517 MP3CV Jules Verne University of Picardie Amiens France
| | - Sylvestre Maréchaux
- EA 7517 MP3CV Jules Verne University of Picardie Amiens France.,Groupement des Hôpitaux de l'Institut Catholique de Lille/Faculté libre de Médecine Université Lille Nord de France Lille France
| | - Christophe Tribouilloy
- Department of Cardiology Amiens University Hospital Amiens France.,EA 7517 MP3CV Jules Verne University of Picardie Amiens France
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13
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Guzzetti E, Pibarot P, Clavel MA. Normal-flow low-gradient severe aortic stenosis is a frequent and real entity. Eur Heart J Cardiovasc Imaging 2019; 20:1102-1104. [DOI: 10.1093/ehjci/jez211] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ezequiel Guzzetti
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec Heart and Lung Institute, 2725 Chemin Sainte-Foy, Québec city, Quebec, Canada
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec Heart and Lung Institute, 2725 Chemin Sainte-Foy, Québec city, Quebec, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec Heart and Lung Institute, 2725 Chemin Sainte-Foy, Québec city, Quebec, Canada
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