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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; 17:926-936. [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] [MESH Headings] [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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Puls M, Beuthner BE, Topci R, Jacob CF, Steinhaus KE, Paul N, Beißbarth T, Toischer K, Jacobshagen C, Hasenfuß G. Patients with paradoxical low-flow, low-gradient aortic stenosis gain the least benefit from TAVI among all hemodynamic subtypes. Clin Res Cardiol 2024:10.1007/s00392-024-02482-7. [PMID: 38953944 DOI: 10.1007/s00392-024-02482-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 06/17/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Substantial controversy exists regarding the clinical benefit of patients with severe paradoxical low-flow, low-gradient aortic stenosis (PLF-LG AS) from TAVI. Therefore, we compared post-TAVI benefit by long-term mortality (all-cause, CV and SCD), clinical improvement of heart failure symptoms, and cardiac reverse remodelling in guideline-defined AS subtypes. METHODS We prospectively included 250 consecutive TAVI patients. TTE, 6mwt, MLHFQ, NYHA status and NT-proBNP were recorded at baseline and 6 months. Long-term mortality and causes of death were assessed. RESULTS 107 individuals suffered from normal EF, high gradient AS (NEF-HG AS), 36 from low EF, high gradient AS (LEF-HG), 52 from "classic" low-flow, low-gradient AS (LEF-LG AS), and 38 from paradoxical low-flow, low-gradient AS (PLF-LG AS). TAVI lead to a significant decrease in MLHFQ score and NT-proBNP levels in all subtypes except for PLF-LG. Regarding reverse remodelling, a significant increase in EF and decrease in LVEDV was present only in subtypes with reduced baseline EF, whereas a significant decrease in LVMI and LAVI could be observed in all subtypes except for PLF-LG. During a follow-up of 3-5 years, PLF-LG patients exhibited the poorest survival among all subtypes (HR 4.2, P = 0.0002 for CV mortality; HR 7.3, P = 0.004 for SCD, in comparison with NEF-HG). Importantly, PLF-LG was independently predictive for CV mortality (HR 2.9 [1.3-6.9], P = 0.009). CONCLUSIONS PLF-LG patients exhibit the highest mortality (particularly CV and SCD), the poorest symptomatic benefit and the least reverse cardiac remodelling after TAVI among all subtypes. Thus, this cohort seems to gain the least benefit.
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Affiliation(s)
- Miriam Puls
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, 37099, Göttingen, Germany.
| | - Bo Eric Beuthner
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, 37099, Göttingen, Germany
| | - Rodi Topci
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, 37099, Göttingen, Germany
| | | | | | - Niels Paul
- Department of Medical Bioinformatics, University Medical Center Göttingen, 37099, Göttingen, Germany
| | - Tim Beißbarth
- Department of Medical Bioinformatics, University Medical Center Göttingen, 37099, Göttingen, Germany
| | - Karl Toischer
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, 37099, Göttingen, Germany
| | - Claudius Jacobshagen
- Department of Cardiology, Vincentius-Diakonissen Hospital Karlsruhe, 76135, Karlsruhe, Germany
| | - Gerd Hasenfuß
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, 37099, Göttingen, Germany
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Nakase M, Tomii D, Heg D, Praz F, Stortecky S, Lanz J, Reineke D, Windecker S, Pilgrim T. Association of atrial fibrillation with survival in patients with low-flow low-gradient aortic stenosis with preserved ejection fraction undergoing TAVI. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2024; 10:246-255. [PMID: 37491693 DOI: 10.1093/ehjqcco/qcad045] [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: 04/05/2023] [Revised: 06/13/2023] [Accepted: 07/24/2023] [Indexed: 07/27/2023]
Abstract
AIMS There is limited evidence on the prognostic significance of atrial fibrillation (AF) in patients with low flow, low-gradient aortic stenosis with preserved ejection fraction (LFLG-pEF AS). We aimed to evaluate the recovery of stroke volume after transcatheter aortic valve implantation (TAVI) and clinical outcomes in patients with LFLG-pEF AS stratified by presence or absence of AF. METHODS AND RESULTS In a prospective TAVI registry, patients with preserved left ventricular ejection fraction (LVEF ≥ 50%) were stratified according to flow-gradient status and presence of AF. Among 2259 TAVI patients with preserved LVEF between August 2007 and June 2021, 765 had high-gradient AS (HG AS) and 444 had LFLG-pEF AS. AF was observed in 199 patients with HG AS (26.0%) and 190 patients with LFLG-pEF AS (42.8%). At 1 year, stroke volume index (SVi) was significantly improved in LFLG-pEF AS patients without AF, while SVi remained low in patients with AF (from 25.9 ± 8.5 mL/m2 to 37.2 ± 9.9 mL/m2 and from 26.8 ± 5.1 mL/m2 to 26.1 ± 9.1 mL/m2, respectively). LFLG-pEF AS patients with AF had an increased risk of 1-year all-cause mortality compared with those without AF (adjusted hazard ratio (HRadjusted) 2.57; 95% confidence interval [CI] 1.44-4.59). LFLG-pEF AS patients without AF had similar mortality compared with HG AS patients without AF (HRadjusted 0.85; 95% CI 0.49-1.46). CONCLUSION Patients with LFLG-pEF AS and AF experienced no relevant recovery of stroke volume after TAVI, but a more than two-fold increased risk of death compared to patients with HG AS or LFLG-pEF AS without AF. CLINICAL TRIAL REGISTRATION https://www.clinicaltrials.gov. NCT01368250.
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Affiliation(s)
- Masaaki Nakase
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern 3010, Switzerland
| | - Daijiro Tomii
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern 3010, Switzerland
| | - Dik Heg
- CTU Bern, University of Bern, Bern 3010, Switzerland
| | - Fabien Praz
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern 3010, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern 3010, Switzerland
| | - Jonas Lanz
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern 3010, Switzerland
| | - David Reineke
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern 3010, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern 3010, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern 3010, Switzerland
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Ullah W, Sana MK, Mukhtar M, Syed SH, Zahid S, Alkhouli M, Vishnevsky A. Transcatheter Aortic Valve Replacement Across Hemodynamic Subtypes of Severe Aortic Valve Stenosis: A Network Meta-analysis. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101255. [PMID: 39131772 PMCID: PMC11307878 DOI: 10.1016/j.jscai.2023.101255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 11/14/2023] [Accepted: 11/22/2023] [Indexed: 08/13/2024]
Abstract
Background Studies assessing outcomes of transcatheter aortic valve replacement (TAVR) in patients with severe aortic valve stenosis (AS) with hemodynamic subtypes have demonstrated mixed results with respect to outcomes and periprocedural complications. This study aimed to assess the outcomes of TAVR in patients across various hemodynamic subtypes of severe AS. Methods PubMed, Embase, and Cochrane databases were searched through September 2023 to identify all observational studies comparing outcomes of TAVR in patients with paradoxical low flow low gradient (pLFLG), classic LFLG, and high gradient AS (HGAS). The primary outcome was major adverse cardiovascular events (MACE). The secondary outcomes were components of MACE (mortality, myocardial infarction [MI], stroke). A bivariate, influential, and frequentist network meta-analysis model was used to obtain the net odds ratio (OR) with a 95% CI. Results A total of 21 studies comprising 17,298 (8742 experimental and 8556 HGAS) patients were included in the quantitative analysis. TAVR was associated with a significant reduction in the mean aortic gradient, and an increase in the mean aortic valve area irrespective of the AS type. Compared with HGAS, TAVR in classic LFLG had a significantly higher (OR, 1.68; 95% CI, 1.04-2.72), while pLFLG (OR, 0.98; 95% CI, 0.72-1.35) had a statistically similar incidence of MACE at a median follow-up of 1-year. TAVR in LFLG also had a significantly higher need for surgery (OR, 3.57; 95% CI, 1.24-10.32), and a greater risk of periprocedural (OR, 2.00; 95% CI, 1.17-3.41), 1-month (OR, 1.69; 95% CI, 1.08-2.64), and 12-month (OR, 1.41; 95% CI, 1.05-1.88) mortality compared with HGAS. The incidence of MI, major bleeding, vascular complications, paravalvular leak, pacemaker implantation, and rehospitalizations was not significantly different between all other types of AS (HGAS vs LFLG, pLFLG). Conclusions TAVR is an effective strategy in severe AS irrespective of the hemodynamic subtypes. Relatively, pLFLG did not have significantly different risk of periprocedural complications compared with HGAS, while classical LFLG AS had higher risk of MACE, primarily driven by the greater mortality risk.
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Affiliation(s)
- Waqas Ullah
- Department of Cardiology, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Muhammad Khawar Sana
- Department of Cardiology, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois
| | - Maryam Mukhtar
- Department of Cardiology, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Sohaib Hasan Syed
- Department of Cardiology, Saint Mary Mercy Hospital, Livonia, Michigan
| | - Salman Zahid
- Department of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | | | - Alec Vishnevsky
- Department of Cardiology, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
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Carter-Storch R, Hahn RT, Abbas AE, Daubert MA, Douglas PS, Elmariah S, Zhao Y, Mack MJ, Leon MB, Pibarot P, Clavel MA. Effect of Sex and Flow Status on Outcomes After Surgical or Transcatheter Aortic Valve Replacement. JACC. ADVANCES 2024; 3:100853. [PMID: 38938841 PMCID: PMC11198680 DOI: 10.1016/j.jacadv.2024.100853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/13/2023] [Accepted: 11/29/2023] [Indexed: 06/29/2024]
Abstract
Background Low stroke volume index <35 ml/m2 despite preserved ejection fraction (paradoxical low flow [PLF]) is associated with adverse outcomes in patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). However, whether the risk associated with PLF is similar in both sexes is unknown. Objectives The purpose of this study was to analyze the risk associated with PLF in severe aortic stenosis for men and women randomized to TAVR or SAVR. Methods Patients with ejection fraction ≥50% from the PARTNER (Placement of Aortic Transcatheter Valves) 2 and 3 trials were stratified by sex and treatment arm. The impact of PLF on the 2-year occurrence of the composite of death or heart failure hospitalization (primary endpoint) and of all-cause mortality alone (secondary endpoint) was analyzed. Analysis of variance was used to assess baseline differences between groups. Multivariate Cox regression analysis was used to identify predictors of the endpoint. Results Out of 2,242 patients, PLF was present in 390 men and 239 women (30% vs 26%, P = 0.06). PLF was associated with a higher rate of NYHA functional class III to IV dyspnea (60% vs 54%, P < 0.001) and a higher prevalence of atrial fibrillation (39% vs 24%, P < 0.001). PLF was a significant predictor of the primary endpoint among women undergoing SAVR in multivariate analysis (adjusted HR: 2.25 [95% CI: 1.14-4.43], P = 0.02) but was not associated with a worse outcome in any of the other groups (all P > 0.05). Conclusions In women with PLF, TAVR may improve outcomes compared to SAVR. PLF appears to have less impact on outcomes in men.
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Affiliation(s)
- Rasmus Carter-Storch
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Quebec Heart and Lung Institute, Laval University, Quebec, Quebec, Canada
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Rebecca T. Hahn
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Amr E. Abbas
- Corewell Health, William Beaumont University Hospital, Royal Oak, Michigan, USA
| | | | | | - Sammy Elmariah
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yanglu Zhao
- Edwards Lifesciences, Irvine, California, USA
| | | | | | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Quebec Heart and Lung Institute, Laval University, Quebec, Quebec, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Quebec Heart and Lung Institute, Laval University, Quebec, Quebec, Canada
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6
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Pibarot P. Discordant Low-Gradient Aortic Stenosis: Assessing the Valve and the Myocardium. Tex Heart Inst J 2024; 51:238288. [PMID: 38220578 DOI: 10.14503/thij-23-8288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Affiliation(s)
- Philippe Pibarot
- Department of Cardiology, Québec Heart and Lung Institute, Laval University, Québec, QC, Canada
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7
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Pibarot P, Tastet L. Cardiac damage staging in the flow-gradient patterns of aortic stenosis. EUROINTERVENTION 2023; 19:e794-e797. [PMID: 38050995 PMCID: PMC10687641 DOI: 10.4244/eij-e-23-00054] [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] [Indexed: 12/07/2023]
Affiliation(s)
- Philippe Pibarot
- Québec Heart & Lung Institute, Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Québec City, QC, Canada
| | - Lionel Tastet
- Québec Heart & Lung Institute, Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Québec City, QC, Canada
- Department of Medicine (Division of Cardiology), University of California, San Francisco, CA, USA
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Wilde NG, Mauri V, Piayda K, Al-Kassou B, Shamekhi J, Maier O, Tiyerili V, Sugiura A, Weber M, Zimmer S, Zeus T, Kelm M, Adam M, Baldus S, Nickenig G, Veulemans V, Sedaghat A. Left ventricular reverse remodeling after transcatheter aortic valve implantation in patients with low-flow low-gradient aortic stenosis. Hellenic J Cardiol 2023; 74:1-7. [PMID: 37119968 DOI: 10.1016/j.hjc.2023.04.009] [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: 01/12/2023] [Revised: 04/23/2023] [Accepted: 04/25/2023] [Indexed: 05/01/2023] Open
Abstract
OBJECTIVES Left ventricular reverse remodeling (LVRR) is associated with improved outcome in patients with heart failure. Factors associated with and predictive of LVRR in patients with low-flow low-gradient aortic stenosis (LFLG AS) after transcatheter aortic valve implantation (TAVI) and its impact on outcome were assessed. METHODS Pre- and postprocedural left ventricular (LV) function and volume were investigated in 219 patients with LFLG. LVRR was defined as an absolute increase of ≥10% in LV ejection fraction (LVEF) and reduction of ≥15% in LV end-systolic volume (LVESV). The primary endpoint was the combination of all-cause mortality and rehospitalization for heart failure. RESULTS The mean LVEF was 35.0 ± 10.0%, with a stroke volume index (SVI) of 25.9 ± 6.0 mL/m2 and LVESV of 94.04 ± 46.0 mL. At a median of 5.2 months (interquartile range, 2.7-8.1 months), 77.2% (n = 169) of the patients showed echocardiographic evidence of LVRR. A multivariate model revealed three independent factors for LVRR after TAVI: SVI of <25 mL/m2 (hazard ratio [HR], 2.31; 95% confidence interval [CI], 1.08-3.58; p < 0.01), LVEF of <30% (HR, 2.76; 95% CI, 1.53-2.91; p < 0.01), and valvulo-arterial impedance (Zva) of <5 mmHg/mL/m2 (HR, 5.36; 95% CI, 1.80-15.98; p < 0.01). Patients without evidence of LVRR showed a significantly higher incidence of the 1-year combined endpoint (32 [64.0%] vs. 75 [44.4%], p < 0.01). CONCLUSIONS The majority of patients with LFLG AS show LVRR after TAVI, which is associated with favorable outcomes. An SVI of <25 mL/m2, LVEF of <30%, and Zva < 5mmHg/mL/m2 represent predictors of LVRR.
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Affiliation(s)
- Nihal G Wilde
- Heart Centre Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Victor Mauri
- Heart Centre Cologne, Department of Cardiology, University Hospital Cologne, Cologne, Germany
| | - Kerstin Piayda
- Department of Cardiology, Pulmonology, and Angiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Baravan Al-Kassou
- Heart Centre Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Jasmin Shamekhi
- Heart Centre Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Oliver Maier
- Department of Cardiology, Pulmonology, and Angiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Vedat Tiyerili
- Department of Internal Medicine, St.-Johannes-Hospital Dortmund, Dortmund, Germany
| | - Atsushi Sugiura
- Heart Centre Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Marcel Weber
- Heart Centre Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Sebastian Zimmer
- Heart Centre Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Tobias Zeus
- Department of Cardiology, Pulmonology, and Angiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology, and Angiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Matti Adam
- Heart Centre Cologne, Department of Cardiology, University Hospital Cologne, Cologne, Germany
| | - Stephan Baldus
- Heart Centre Cologne, Department of Cardiology, University Hospital Cologne, Cologne, Germany
| | - Georg Nickenig
- Heart Centre Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Verena Veulemans
- Department of Cardiology, Pulmonology, and Angiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Alexander Sedaghat
- Heart Centre Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany; RheinAhrCardio - Praxis für Kardiologie, Bad Neuenahr-Ahrweiler, Germany.
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Jakulla RS, Gunta SP, Huded CP. Heart Failure after Aortic Valve Replacement: Incidence, Risk Factors, and Implications. J Clin Med 2023; 12:6048. [PMID: 37762989 PMCID: PMC10531882 DOI: 10.3390/jcm12186048] [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: 08/25/2023] [Revised: 09/08/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
Severe aortic stenosis (AS) carries a poor prognosis with the onset of heart failure (HF) symptoms, and surgical or transcatheter aortic valve replacement (AVR) is its only definitive treatment. The management of AS has seen a paradigm shift with the adoption of transcatheter aortic valve replacement (TAVR), allowing for the treatment of AS in patients who would not otherwise be candidates for surgical AVR. Despite improving long-term survival after TAVR in recent years, residual HF symptoms and HF hospitalization are common and are associated with an increased mortality and a poor health status. This review article summarizes the incidence and risk factors for HF after AVR. Strategies for preventing and better managing HF after AVR are necessary to improve outcomes in this patient population. Extensive research is underway to assess whether earlier timing for AVR, prior to the development of severe symptomatic AS and associated extra-valvular cardiac damage, can improve post-AVR patient outcomes.
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Affiliation(s)
- Roopesh Sai Jakulla
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO 64110, USA
| | - Satya Preetham Gunta
- Department of Cardiology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Chetan P. Huded
- Department of Cardiology, University of Missouri-Kansas City, Kansas City, MO 64110, USA
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10
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Sato K, Seo Y, Ishizu T, Albakaa NK, Izumo M, Okada A, Izumi C, Inami S, Takeda Y, Onishi T, Izumi Y, Kumagai A, Fukuda T, Takahashi N, Kitai T, Iwano H, Sugawara S, Akasaka K, Harada K, Masaoka Y, Kusunose K, Tanabe K, Sakamoto T, Takamura T, Ieda M. Cardiac Reversibility and Survival After Transcatheter Aortic Valve Implantation in Patients With Low-Gradient Aortic Stenosis. J Am Heart Assoc 2023; 12:e029717. [PMID: 37581389 PMCID: PMC10492952 DOI: 10.1161/jaha.123.029717] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/11/2023] [Indexed: 08/16/2023]
Abstract
Background Prognostic implications of transcatheter aortic valve implantation (TAVI) in low-gradient (LG) aortic stenosis (AS) remain controversial. The authors hypothesized that differences in cardiac functional recovery may solve this ongoing controversy. The aim was to evaluate clinical outcomes and the response of left ventricular (LV) function following TAVI in patients with LG AS. Methods and Results This multicenter retrospective study included 1742 patients with severe AS undergoing TAVI between January 2015 and March 2019. Patients were subdivided into low-flow (LF) LG, normal-flow (NF) LG, LF high-gradient, and NF high-gradient AS groups according to the mean gradient of the aortic valve (LG <40 mm Hg) and LV stroke volume index (LF <35 mL/m2). Outcomes and changes in echocardiographic parameters after TAVI were compared between the groups. A total of 227 patients (13%) had reduced ejection fraction, and 486 patients (28%) had LG AS (LF-LG 143 [8%]; NF-LG 343 [20%]). During a median follow-up period of 747 days, 301 patients experienced a composite end point of cardiovascular death and rehospitalization for cardiovascular events, which was higher in the LF-LG and NF-LG groups than in the high-gradient groups. LG AS was independently associated with the primary outcome (hazard ratio, 1.69; P<0.001). Among 1239 patients with follow-up echocardiography, LG AS showed less improvement in the LV mass index and LV end-diastolic volume compared with high-gradient AS after 1 year, while LV recovery was similar between the LF AS and NF AS groups. Conclusions LG AS was associated with poorer outcomes and LV recovery, regardless of flow status after TAVI. Careful evaluation of AS severity may be required in LG AS to provide TAVI within the appropriate time and advanced care afterward.
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Affiliation(s)
- Kimi Sato
- Department of Cardiology, Faculty of MedicineUniversity of TsukubaTsukubaJapan
| | - Yoshihiro Seo
- Department of CardiologyNagoya City University Graduate School of Medical SciencesNagoyaJapan
| | - Tomoko Ishizu
- Department of Cardiology, Faculty of MedicineUniversity of TsukubaTsukubaJapan
| | - Noor K. Albakaa
- Department of Cardiology, Faculty of MedicineUniversity of TsukubaTsukubaJapan
| | - Masaki Izumo
- Division of CardiologySt. Marianna Medical University HospitalKawasakiJapan
| | - Atsushi Okada
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterOsakaJapan
| | - Chisato Izumi
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterOsakaJapan
| | - Shu Inami
- Department of Cardiovascular MedicineDokkyo Medical UniversityMibuJapan
| | - Yasuharu Takeda
- Department of Cardiovascular MedicineOsaka University Graduate School of MedicineSuitaJapan
| | - Toshinari Onishi
- Department of Cardiovascular MedicineSakai City Hospital OrganizationSakaiJapan
| | - Yuki Izumi
- Department of CardiologySakakibara Heart InstituteTokyoJapan
| | - Akiko Kumagai
- Division of Cardiology, Department of Internal MedicineIwate Medical UniversityIwateJapan
| | - Tomoko Fukuda
- Department of Cardiology and Clinical Examination, Faculty of MedicineOita UniversityOitaJapan
| | - Naohiko Takahashi
- Department of Cardiology and Clinical Examination, Faculty of MedicineOita UniversityOitaJapan
| | - Takeshi Kitai
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterOsakaJapan
- Department of Cardiovascular MedicineKobe City Medical Center General HospitalKobeJapan
| | - Hiroyuki Iwano
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of MedicineHokkaido UniversitySapporoJapan
- Division of CardiologyTeine Keijinkai HospitalSapporoJapan
| | - Shigeo Sugawara
- Department of CardiologyNihonkai General HospitalYamagataJapan
| | - Kazumi Akasaka
- Medical Laboratory and Blood CenterAsahikawa Medical University HospitalAsahikawaJapan
| | - Kenji Harada
- Division of Cardiovascular Medicine, Department of Internal MedicineJichi Medical UniversityTochigiJapan
| | - Yoshiko Masaoka
- Department of CardiologyHiroshima City Hiroshima Citizens HospitalHiroshimaJapan
| | - Kenya Kusunose
- Department of Cardiovascular MedicineTokushima University HospitalTokushimaJapan
| | - Kazuaki Tanabe
- Division of CardiologyShimane University Faculty of MedicineIzumoJapan
| | - Takahiro Sakamoto
- Division of CardiologyShimane University Faculty of MedicineIzumoJapan
| | | | - Masaki Ieda
- Department of Cardiology, Faculty of MedicineUniversity of TsukubaTsukubaJapan
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11
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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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12
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Pibarot P, Clavel MA. Discordant Low-Gradient Aortic Stenosis With Preserved Left Ventricular Ejection Fraction: Setting the Record Straight. JACC. ADVANCES 2023; 2:100263. [PMID: 38938295 PMCID: PMC11198696 DOI: 10.1016/j.jacadv.2023.100263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
- Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec, Canada
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13
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Fukui M, Annabi MS, Rosa VEE, Ribeiro HB, Stanberry LI, Clavel MA, Rodés-Cabau J, Tarasoutchi F, Schelbert EB, Bergler-Klein J, Bartko PE, Dona C, Mascherbauer J, Dahou A, Rochitte CE, Pibarot P, Cavalcante JL. Comprehensive myocardial characterization using cardiac magnetic resonance associates with outcomes in low gradient severe aortic stenosis. Eur Heart J Cardiovasc Imaging 2022; 24:46-58. [PMID: 35613021 DOI: 10.1093/ehjci/jeac089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 04/21/2022] [Accepted: 04/25/2022] [Indexed: 12/24/2022] Open
Abstract
AIMS This study sought to compare cardiac magnetic resonance (CMR) characteristics according to different flow/gradient patterns of aortic stenosis (AS) and to evaluate their prognostic value in patients with low-gradient AS. METHODS AND RESULTS This international prospective multicentric study included 147 patients with low-gradient moderate to severe AS who underwent comprehensive CMR evaluation of left ventricular global longitudinal strain (LVGLS), extracellular volume fraction (ECV), and late gadolinium enhancement (LGE). All patients were classified as followings: classical low-flow low-gradient (LFLG) [mean gradient (MG) < 40 mmHg and left ventricular ejection fraction (LVEF) < 50%]; paradoxical LFLG [MG < 40 mmHg, LVEF ≥ 50%, and stroke volume index (SVi) < 35 ml/m2]; and normal-flow low-gradient (MG < 40 mmHg, LVEF ≥ 50%, and SVi ≥ 35 ml/m2). Patients with classical LFLG (n = 90) had more LV adverse remodelling including higher ECV, and higher LGE and volume, and worst LVGLS. Over a median follow-up of 2 years, 43 deaths and 48 composite outcomes of death or heart failure hospitalizations occurred. Risks of adverse events increased per tertile of LVGLS: hazard ratio (HR) = 1.50 [95% CI, 1.02-2.20]; P = 0.04 for mortality; HR = 1.45 [1.01-2.09]; P < 0.05 for composite outcome; per tertile of ECV, HR = 1.63 [1.07-2.49]; P = 0.02 for mortality; HR = 1.54 [1.02-2.33]; P = 0.04 for composite outcome. LGE presence also associated with higher mortality, HR = 2.27 [1.01-5.11]; P < 0.05 and composite outcome, HR = 3.00 [1.16-7.73]; P = 0.02. The risk of mortality and the composite outcome increased in proportion to the number of impaired components (i.e. LVGLS, ECV, and LGE) with multivariate adjustment. CONCLUSIONS In this international prospective multicentric study of low-gradient AS, comprehensive CMR assessment provides independent prognostic value that is cumulative and incremental to clinical and echocardiographic characteristics.
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Affiliation(s)
- Miho Fukui
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, 920 E 28th Street, Suite 100, 55407 Minneapolis, MN, USA
| | - Mohamed-Salah Annabi
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Québec, Canada
| | - Vitor E E Rosa
- Heart Institute of Sao Paulo (InCor), University of Sao Paulo, Sao Paulo, Brazil
| | - Henrique B Ribeiro
- Heart Institute of Sao Paulo (InCor), University of Sao Paulo, Sao Paulo, Brazil
| | - Larissa I Stanberry
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, 920 E 28th Street, Suite 100, 55407 Minneapolis, MN, USA
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Québec, Canada
| | - Josep Rodés-Cabau
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Québec, Canada
| | - Flavio Tarasoutchi
- Heart Institute of Sao Paulo (InCor), University of Sao Paulo, Sao Paulo, Brazil
| | - Erik B Schelbert
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jutta Bergler-Klein
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Philipp E Bartko
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Carolina Dona
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Julia Mascherbauer
- Department of Internal Medicine 3, Karl Landsteiner University of Health Sciences, University Hospital St. Pölten, Krems, Austria
| | | | - Carlos E Rochitte
- Heart Institute of Sao Paulo (InCor), University of Sao Paulo, Sao Paulo, Brazil
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Québec, Canada
| | - João L Cavalcante
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, 920 E 28th Street, Suite 100, 55407 Minneapolis, MN, USA
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14
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Steffen J, Reißig N, Andreae D, Beckmann M, Haum M, Fischer J, Theiss H, Braun D, Orban M, Rizas K, Sadoni S, Näbauer M, Peterss S, Hausleiter J, Massberg S, Deseive S. TAVI in patients with low-flow low-gradient aortic stenosis-short-term and long-term outcomes. Clin Res Cardiol 2022; 111:1325-1335. [PMID: 35320407 PMCID: PMC9681695 DOI: 10.1007/s00392-022-02011-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 03/10/2022] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The study objective was to characterize different groups of low-flow low-gradient (LFLG) aortic stenosis (AS) and determine short-term outcomes and long-term mortality according to Valve Academic Research Consortium-3 (VARC-3) endpoint definitions. BACKGROUND Characteristics and outcomes of patients with LFLG AS undergoing transcatheter aortic valve implantation (TAVI) are poorly understood. METHODS All patients undergoing TAVI at our center between 2013 and 2019 were screened. Patients were divided into three groups according to mean pressure gradient (dPmean), ejection fraction (LVEF), and stroke volume index (SVi): high gradient (HG) AS (dPmean ≥ 40 mmHg), classical LFLG (cLFLG) AS (dPmean < 40 mmHg, LVEF < 50%), and paradoxical LFLG (pLFLG) AS (dPmean < 40 mmHg, LVEF ≥ 50%, SVi ≤ 35 ml/m2). RESULTS We included 1776 patients (956 HG, 447 cLFLG, and 373 pLFLG patients). Most baseline characteristics differed significantly. Median Society of Thoracic Surgeons (STS) score was highest in cLFLG, followed by pLFLG and HG patients (5.0, 3.9 and 3.0, respectively, p < 0.01). Compared to HG patients, odds ratios for the short-term VARC-3 composite endpoints, technical failure (cLFLG, 0.76 [95% confidence interval, 0.40-1.36], pLFLG, 1.37 [0.79-2.31]) and device failure (cLFLG, 1.06 [0.74-1.49], pLFLG, 0.97 [0.66-1.41]) were similar, without relevant differences within LFLG patients. NYHA classes improved equally in all groups. Compared to HG, LFLG patients had a higher 3-year all-cause mortality (STS score-adjusted hazard ratios, cLFLG 2.16 [1.77-2.64], pLFLG 1.53 [1.22-193]), as well as cardiovascular mortality (cLFLG, 2.88 [2.15-3.84], pLFLG, 2.08 [1.50-2.87]). CONCLUSIONS While 3-year mortality remains high after TAVI in LFLG compared to HG patients, symptoms improve in all subsets after TAVI.
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Affiliation(s)
- Julius Steffen
- Medizinische Klinik und Poliklinik I, LMU Klinikum, LMU München, Marchioninistr. 15, 81377, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner site Munich, Munich, Germany
| | - Nikolas Reißig
- Medizinische Klinik und Poliklinik I, LMU Klinikum, LMU München, Marchioninistr. 15, 81377, Munich, Germany
| | - David Andreae
- Medizinische Klinik und Poliklinik I, LMU Klinikum, LMU München, Marchioninistr. 15, 81377, Munich, Germany
| | - Markus Beckmann
- Medizinische Klinik und Poliklinik I, LMU Klinikum, LMU München, Marchioninistr. 15, 81377, Munich, Germany
| | - Magda Haum
- Medizinische Klinik und Poliklinik I, LMU Klinikum, LMU München, Marchioninistr. 15, 81377, Munich, Germany
| | - Julius Fischer
- Medizinische Klinik und Poliklinik I, LMU Klinikum, LMU München, Marchioninistr. 15, 81377, Munich, Germany
| | - Hans Theiss
- Medizinische Klinik und Poliklinik I, LMU Klinikum, LMU München, Marchioninistr. 15, 81377, Munich, Germany
| | - Daniel Braun
- Medizinische Klinik und Poliklinik I, LMU Klinikum, LMU München, Marchioninistr. 15, 81377, Munich, Germany
| | - Martin Orban
- Medizinische Klinik und Poliklinik I, LMU Klinikum, LMU München, Marchioninistr. 15, 81377, Munich, Germany
| | - Konstantinos Rizas
- Medizinische Klinik und Poliklinik I, LMU Klinikum, LMU München, Marchioninistr. 15, 81377, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner site Munich, Munich, Germany
| | - Sebastian Sadoni
- Herzchirurgische Klinik und Poliklinik, LMU Klinikum, LMU München, Marchioninistr. 15, 81377, Munich, Germany
| | - Michael Näbauer
- Medizinische Klinik und Poliklinik I, LMU Klinikum, LMU München, Marchioninistr. 15, 81377, Munich, Germany
| | - Sven Peterss
- Herzchirurgische Klinik und Poliklinik, LMU Klinikum, LMU München, Marchioninistr. 15, 81377, Munich, Germany
| | - Jörg Hausleiter
- Medizinische Klinik und Poliklinik I, LMU Klinikum, LMU München, Marchioninistr. 15, 81377, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner site Munich, Munich, Germany
| | - Steffen Massberg
- Medizinische Klinik und Poliklinik I, LMU Klinikum, LMU München, Marchioninistr. 15, 81377, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner site Munich, Munich, Germany
| | - Simon Deseive
- Medizinische Klinik und Poliklinik I, LMU Klinikum, LMU München, Marchioninistr. 15, 81377, Munich, Germany.
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15
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Impact of Surgical and Transcatheter Aortic Valve Replacement in Low-Gradient Aortic Stenosis: A Meta-Analysis. JACC Cardiovasc Interv 2021; 14:1481-1492. [PMID: 33939605 DOI: 10.1016/j.jcin.2021.04.038] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/21/2021] [Accepted: 04/27/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The aim of this study was to assess the impact of aortic valve replacement (AVR) on survival in patients with each subclass of low-gradient (LG) aortic stenosis (AS) and to compare outcomes following surgical AVR (SAVR) and transcatheter AVR (TAVR). BACKGROUND LG severe AS encompasses a wide variety of pathophysiology, including classical low-flow, LG (LF-LG), paradoxical LF-LG, and normal-flow, LG (NF-LG) AS, and uncertainty exists regarding the impact of AVR on each subclass of LG AS. METHODS PubMed and Embase were queried through October 2020 to identify studies comparing survival with different management strategies (SAVR, TAVR, and conservative) in patients with LG AS. Pairwise meta-analysis comparing AVR versus conservative management and network meta-analysis comparing SAVR versus TAVR versus conservative management were performed. RESULTS Thirty-two studies with a total of 6,515 patients and a median follow-up time of 24.2 months (interquartile range: 36.5 months) were included. AVR was associated with a significant decrease in all-cause mortality in classical LF-LG (hazard ratio [HR]: 0.42; 95% confidence interval [CI]: 0.36 to 0.48), paradoxical LF-LG (HR: 0.41; 95% CI: 0.29 to 0.57), and NF-LG (HR: 0.41; 95% CI: 0.27 to 0.62) AS compared with conservative management. SAVR and TAVR were each associated with a decrease in all-cause mortality in classical LF-LG (HR: 0.46 [95% CI: 0.38 to 0.55] and 0.49 [95% CI: 0.37 to 0.64], respectively), paradoxical LF-LG (HR: 0.42 [95% CI: 0.28 to 0.65] and 0.42 [95% CI: 0.25 to 0.72], respectively), and NF-LG (HR: 0.40 [95% CI: 0.21 to 0.77] and 0.46 [95% CI: 0.26 to 0.84], respectively) AS compared with conservative management. No significant difference was observed between SAVR and TAVR. CONCLUSIONS In all subclasses of LG AS, AVR was associated with a significant decrease in all-cause mortality regardless of surgical or transcatheter approach.
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16
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Mosleh W, Amer MR, Ding Y, Megaly M, Mather JF, McMahon S, Pershad A, McKay RG, Arora B. Benefit of Transcatheter Aortic Valve Replacement in Patients With Paradoxical Low-Flow Low-Gradient Versus High-Gradient Aortic Stenosis and Preserved Left Ventricular Function. Circ Cardiovasc Interv 2021; 14:e010042. [PMID: 33685217 DOI: 10.1161/circinterventions.120.010042] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Wassim Mosleh
- Division of Cardiology, University of Connecticut, Farmington (W.M., Y.D.)
| | - Mostafa R Amer
- Division of Cardiology, Lankenau Heart Institute/Main Line Health, Wynnewood, PA (M.R.A.)
| | - Yuewen Ding
- Division of Cardiology, University of Connecticut, Farmington (W.M., Y.D.)
| | - Michael Megaly
- Division of Interventional Cardiology, Banner University Medical Center/University of Arizona, Phoenix (M.M., A.P.)
| | - Jeffrey F Mather
- Division of Research Administration, Hartford Hospital, CT (J.F.M.)
| | - Sean McMahon
- Division of Cardiology, Hartford Hospital, CT (S.M., R.G.M., B.A.)
| | - Ashish Pershad
- Division of Interventional Cardiology, Banner University Medical Center/University of Arizona, Phoenix (M.M., A.P.)
| | - Raymond G McKay
- Division of Cardiology, Hartford Hospital, CT (S.M., R.G.M., B.A.)
| | - Bhaskar Arora
- Division of Cardiology, Hartford Hospital, CT (S.M., R.G.M., B.A.)
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17
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Gupta T, Joseph DT, Goel SS, Kleiman NS. Predicting and measuring mortality risk after transcatheter aortic valve replacement. Expert Rev Cardiovasc Ther 2021; 19:247-260. [PMID: 33560150 DOI: 10.1080/14779072.2021.1888715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Over the last decade, transcatheter aortic valve replacement (TAVR) has emerged as a treatment option for most patients with severe symptomatic aortic stenosis (AS). With growing indications and exponential increase in the number of TAVR procedures, it is important to be able to accurately predict mortality after TAVR.Areas covered: Herein, we review the surgical and TAVR-specific mortality prediction models (MPMs) and their performance in their original derivation and external validation cohorts. We then discuss the role of other important risk assessment tools such as frailty, echocardiographic parameters, and biomarkers in patients, being considered for TAVR.Expert opinion: Conventional surgical MPMs have suboptimal predictive performance and are mis-calibrated when applied to TAVR populations. Although a number of TAVR-specific MPMs have been developed, their utility is also limited by their modest discriminative ability when applied to populations external to their original derivation cohorts. There is an unmet need for robust TAVR MPMs that accurately predict post TAVR mortality. In the interim, heart teams should utilize the currently available TAVR-specific MPMs in conjunction with other prognostic factors, such as frailty, echocardiographic or computed tomography (CT) imaging parameters, and biomarkers for risk assessment of patients, being considered for TAVR.
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Affiliation(s)
- Tanush Gupta
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
| | - Denny T Joseph
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
| | - Sachin S Goel
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
| | - Neal S Kleiman
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
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18
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Ternacle J, Faroux L, Alperi A, Muntané-Carol G, Delarochellière R, Paradis JM, Kalavrouziotis D, Mohammadi S, Dumont E, Beaudoin J, Bernier M, Côté N, Côté M, Vincent F, Clavel MA, Rodés-Cabau J, Pibarot P. Impact of Left-Ventricular Dysfunction in Patients With High- and Low- Gradient Severe Aortic Stenosis Following Transcatheter Aortic Valve Replacement. Can J Cardiol 2020; 37:1103-1111. [PMID: 33161147 DOI: 10.1016/j.cjca.2020.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 10/14/2020] [Accepted: 10/30/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Outcomes of transcatheter aortic valve replacement (TAVR) in patients with high-gradient (HG) severe aortic stenosis (AS) and reduced left-ventricular (LV) ejection fraction (EF) are unknown. METHODS Patients undergoing TAVR for native severe AS between 2009 and 2018 were retrospectively included and classified into 3 groups: HG (≥ 40 mm Hg) and preserved EF (≥ 50%), HG low EF (< 50%), and low gradient (LG < 40 mm Hg) low EF. The primary endpoint was a composite of cardiovascular mortality and readmission for heart failure at 1 year after TAVR. RESULTS Of the 526 patients included, 323 (61%) had HG preserved EF, 69 (13%) had HG low EF, and 134 (26%) had LG low EF. HG low EF group had higher prevalence of atrial fibrillation and heart failure and higher Society of Thoracic Surgeons score compared with the HG preserved EF group. Patients in the LG low EF group were older and had higher prevalence of coronary artery disease compared with those in the HG groups. All-cause mortality at 30 days (4.0%) was similar across the 3 groups. After adjustment, the risk of primary endpoint was similar in the HG low-EF vs preserved EF groups. Conversely, the risk of primary endpoint was higher in the LG low EF group vs the HG preserved EF group (hazard ratio [HR], 2.24; 95% confidence interval [CI],1.36-3.70; P = 0.002) and vs HG low EF group (HR, 3.50; 95% CI, 1.55-7.90; P = 0.003), whereas the risk of all-cause mortality was similar across the 3 groups. CONCLUSIONS The outcome of patients with HG low EF severe AS following TAVR is as good as that of patients with HG preserved EF.
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Affiliation(s)
- Julien Ternacle
- Institut universitaire de cardiologie et de pneumologie de Québec- Université Laval/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Laurent Faroux
- Institut universitaire de cardiologie et de pneumologie de Québec- Université Laval/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Alberto Alperi
- Institut universitaire de cardiologie et de pneumologie de Québec- Université Laval/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Guillem Muntané-Carol
- Institut universitaire de cardiologie et de pneumologie de Québec- Université Laval/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Robert Delarochellière
- Institut universitaire de cardiologie et de pneumologie de Québec- Université Laval/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Jean-Michel Paradis
- Institut universitaire de cardiologie et de pneumologie de Québec- Université Laval/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Dimitri Kalavrouziotis
- Institut universitaire de cardiologie et de pneumologie de Québec- Université Laval/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Siamak Mohammadi
- Institut universitaire de cardiologie et de pneumologie de Québec- Université Laval/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Eric Dumont
- Institut universitaire de cardiologie et de pneumologie de Québec- Université Laval/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Jonathan Beaudoin
- Institut universitaire de cardiologie et de pneumologie de Québec- Université Laval/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Mathieu Bernier
- Institut universitaire de cardiologie et de pneumologie de Québec- Université Laval/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Nancy Côté
- Institut universitaire de cardiologie et de pneumologie de Québec- Université Laval/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Mélanie Côté
- Institut universitaire de cardiologie et de pneumologie de Québec- Université Laval/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Flavien Vincent
- Institut universitaire de cardiologie et de pneumologie de Québec- Université Laval/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Marie-Annick Clavel
- Institut universitaire de cardiologie et de pneumologie de Québec- Université Laval/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Josep Rodés-Cabau
- Institut universitaire de cardiologie et de pneumologie de Québec- Université Laval/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Philippe Pibarot
- Institut universitaire de cardiologie et de pneumologie de Québec- Université Laval/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada.
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