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Onoda H, Imamura T, Ueno H, Oshima A, Ushijima R, Sobajima M, Kinugawa K. Paradoxical prognostic impact of severe aortic stenosis following trans-catheter aortic valve implantation. J Cardiol 2024; 84:311-316. [PMID: 38580175 DOI: 10.1016/j.jjcc.2024.03.010] [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: 01/01/2024] [Revised: 02/25/2024] [Accepted: 03/21/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Aortic valve replacement is recommended for patients with "very severe" aortic stenosis (AS), irrespective of symptomatic manifestation. Nonetheless, the prognostic ramifications of "very severe" AS, as opposed to "severe" AS, subsequent to trans-catheter aortic valve implantation (TAVI) remain enigmatic. METHODS We enrolled consecutive patients who received TAVI at our institute between May 2015 and April 2021. We scrutinized the impact of baseline "very severe" AS upon 3-year all-cause death or heart failure hospitalization following TAVI, in comparison to "severe" AS. RESULTS A total of 239 patients (84.8 ± 5.4 years old, 58 men) were included. Baseline "very severe" AS was observed in 65 (27 %) patients, who exhibited more advanced hypertrophy and higher B-type natriuretic peptide levels compared to those with "severe" AS (p < 0.05 for both). Baseline "very severe" AS was paradoxically associated with higher freedom from the primary endpoint following TAVI compared to those with "severe" AS (p = 0.01). CONCLUSIONS The presence of baseline "very severe" AS was paradoxically associated with improved clinical outcomes subsequent to TAVI, in contrast to the cases of "severe" AS.
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Affiliation(s)
- Hiroshi Onoda
- The Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Teruhiko Imamura
- The Second Department of Internal Medicine, University of Toyama, Toyama, Japan.
| | - Hiroshi Ueno
- The Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Akira Oshima
- The Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Ryuichi Ushijima
- The Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Mitsuo Sobajima
- The Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Koichiro Kinugawa
- The Second Department of Internal Medicine, University of Toyama, Toyama, Japan
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Lee SH, Yoon SJ, Sun BJ, Kim HM, Kim HY, Lee S, Shim CY, Kim EK, Cho DH, Park JB, Seo JS, Son JW, Kim IC, Lee SH, Heo R, Lee HJ, Park JH, Song JM, Lee SC, Kim H, Kang DH, Ha JW, Kim KH. 2023 Korean Society of Echocardiography position paper for diagnosis and management of valvular heart disease, part I: aortic valve disease. J Cardiovasc Imaging 2024; 32:11. [PMID: 39061115 PMCID: PMC11282617 DOI: 10.1186/s44348-024-00019-0] [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: 09/06/2023] [Accepted: 11/24/2023] [Indexed: 07/28/2024] Open
Abstract
This manuscript represents the official position of the Korean Society of Echocardiography on valvular heart diseases. This position paper focuses on the clinical management of valvular heart diseases with reference to the guidelines recently published by the American College of Cardiology/American Heart Association and the European Society of Cardiology. The committee tried to reflect the recently published results on the topic of valvular heart diseases and Korean data by a systematic literature search based on validity and relevance. In part I of this article, we will review and discuss the current position of aortic valve disease in Korea.
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Affiliation(s)
- Sun Hwa Lee
- Division of Cardiology, Department of Internal Medicine, Jeonbuk National University Medical School, Jeonbuk National University Hospital, Jeonju, Republic of Korea
| | - Se-Jung Yoon
- Division of Cardiology, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Byung Joo Sun
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyue Mee Kim
- Division of Cardiology, Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Hyung Yoon Kim
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Sahmin Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chi Young Shim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Kyoung Kim
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Heart Vascular Stroke Institute, Samsung Medical Center, Seoul, Republic of Korea
| | - Dong-Hyuk Cho
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Jun-Bean Park
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jeong-Sook Seo
- Division of Cardiology, Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Jung-Woo Son
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - In-Cheol Kim
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Sang-Hyun Lee
- Division of Cardiology, Pusan National Yangsan Hospital, Pusan National University School of Medicine, Busan, Republic of Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National Yangsan Hospital, Busan, Republic of Korea
| | - Ran Heo
- Division of Cardiology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Hyun-Jung Lee
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae-Hyeong Park
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Regional Cardiocerebrovascular Center, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Jong-Min Song
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Chol Lee
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Heart Vascular Stroke Institute, Samsung Medical Center, Seoul, Republic of Korea
| | - Hyungseop Kim
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Duk-Hyun Kang
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong-Won Ha
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kye Hun Kim
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea.
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3
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Tan JTA, He GS, Chia JLL, Tan GQX, Teo YN, Teo YH, Syn NL, Chai P, Wong RCC, Yeo TC, Kong WKF, Poh KK, Sia CH. Natural history of initially asymptomatic severe aortic stenosis: a one-stage meta-analysis. Clin Res Cardiol 2024:10.1007/s00392-024-02465-8. [PMID: 39009912 DOI: 10.1007/s00392-024-02465-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 05/16/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Current guidelines on the management strategy for patients with asymptomatic severe aortic stenosis (AS) remain unclear. This uncertainty stems from the lack of data regarding the natural history of these patients. To address this gap, we performed a systematic review and meta-analysis examining the natural history of asymptomatic severe AS patients receiving conservative treatment. METHODS The PubMed, Cochrane, and Embase databases were searched from inception to 24 January 2024 using the keywords "asymptomatic" AND "aortic" AND "stenosis". We included studies examining patients with asymptomatic severe AS. In interventional trials, only data from conservatively managed arms were collected. A one-stage meta-analysis was conducted using individual patient data reconstructed from published Kaplan-Meier curves. Sensitivity analysis was performed for major adverse cardiovascular outcomes in patients who remained asymptomatic throughout follow-up. RESULTS A total of 46 studies were included (n = 9545). The median time to the development of symptoms was 1.11 years (95% CI 0.90-1.53). 49.36% (40.85-58.59) of patients who were asymptomatic had suffered a major adverse cardiovascular event by 5 years. The median event-free time for heart failure hospitalization (HFH) was 5.50 years (95% CI 5.14-5.91) with 36.34% (95% CI 33.34-39.41) of patients experiencing an HFH by year 5. By 5 years, 79.81% (95% CI 69.26-88.58) of patients developed symptoms (angina, dyspnoea, syncope and others) and 12.36% (95% CI 10.01-15.22) of patients died of cardiovascular causes. For all-cause mortality, the median survival time was 9.15 years (95% CI 8.50-9.96) with 39.43% (CI 33.41-36.40) of patients dying by 5 years. The median time to AVR was 4.77 years (95% CI 4.39-5.17), with 52.64% (95% CI 49.85-55.48) of patients requiring an AVR by 5 years. CONCLUSION Our results reveal poor cardiovascular outcomes for patients with asymptomatic severe AS on conservative treatment. A significant proportion eventually requires an AVR. Further research is needed to determine if early intervention with AVR is more effective than conservative treatment.
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Affiliation(s)
- Joshua Teik Ann Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - George Shiyao He
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jolene Li Ling Chia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Gladys Qiao Xuan Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yao Neng Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yao Hao Teo
- Department of Medicine, National University Hospital, Singapore, Singapore
| | - Nicholas L Syn
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ping Chai
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore
| | - Raymond C C Wong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore
| | - Tiong-Cheng Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore
| | - William K F Kong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore
| | - Kian-Keong Poh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore.
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Chen SY, Kong XQ, Zhang JJ. Pathological Mechanism and Treatment of Calcified Aortic Stenosis. Cardiol Rev 2024; 32:320-327. [PMID: 38848535 DOI: 10.1097/crd.0000000000000510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Abstract
Calcified aortic stenosis (AS) is one of the most common valvular heart diseases worldwide, characterized by progressive fibrocalcific remodeling and thickening of the leaflets, which ultimately leads to obstruction of blood flow. Its pathobiology is an active and complicated process, involving endothelial cell dysfunction, lipoprotein deposition and oxidation, chronic inflammation, phenotypic transformation of valve interstitial cells, neovascularization, and intravalvular hemorrhage. To date, no targeted drug has been proven to slow down or prevent disease progression. Aortic valve replacement is still the optimal treatment of AS. This article reviews the etiology, diagnosis, and management of calcified aortic stenosis and proposes novel potential therapeutic targets.
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Affiliation(s)
- Si-Yu Chen
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China, Nanjing 210006, China
| | - Xiang-Quan Kong
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China, Nanjing 210006, China
- Department of Cardiology, Nanjing Heart Centre, Nanjing, China
| | - Jun-Jie Zhang
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China, Nanjing 210006, China
- Department of Cardiology, Nanjing Heart Centre, Nanjing, China
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5
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Banovic M, Iung B, Putnik S, Mahendiran T, Vanderheyden M, Barbato E, Bartunek J. Asymptomatic Aortic Stenosis: From Risk Stratification to Treatment. Am J Cardiol 2024; 218:51-62. [PMID: 38432341 DOI: 10.1016/j.amjcard.2024.02.034] [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: 10/02/2023] [Revised: 02/05/2024] [Accepted: 02/23/2024] [Indexed: 03/05/2024]
Abstract
Our understanding of the natural history of aortic stenosis has significantly increased over the last decade. There have been considerable advances in the diagnosis and risk stratification of patients with aortic stenosis and in surgical and anesthetic techniques. In addition, transcatheter aortic valve replacement has established itself as a viable alternative to surgical management. Inevitably, these developments have raised questions regarding the merits of waiting for symptom onset in asymptomatic patients with severe aortic stenosis before offering treatment. Recent observational and randomized trial data suggest that early intervention in asymptomatic patients with severe aortic stenosis and normal left ventricular function may confer a prognostic advantage to a watchful waiting strategy. In this review, we highlight advances in the management and risk stratification of patients with asymptomatic severe aortic stenosis with particular consideration of recent findings supporting early valvular intervention.
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Affiliation(s)
- Marko Banovic
- Cardiology Department, University Clinical Center of Serbia, Belgrade, Serbia; Belgrade Medical Faculty, University of Belgrade, Serbia.
| | - Bernard Iung
- Cardiology Department, Bichat Hospital APHP and Université Paris Cité, France
| | - Svetozar Putnik
- Belgrade Medical Faculty, University of Belgrade, Serbia; Cardiac-Surgery Department, University Clinical Center of Serbia, Belgrade, Serbia
| | - Thabo Mahendiran
- Cardiovascular Center, OLV Hospital, Aalst, Belgium; Cardiology Department, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Emanuele Barbato
- Cardiovascular Center, OLV Hospital, Aalst, Belgium; Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
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6
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Jneid H, Chikwe J, Arnold SV, Bonow RO, Bradley SM, Chen EP, Diekemper RL, Fugar S, Johnston DR, Kumbhani DJ, Mehran R, Misra A, Patel MR, Sweis RN, Szerlip M. 2024 ACC/AHA Clinical Performance and Quality Measures for Adults With Valvular and Structural Heart Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Performance Measures. J Am Coll Cardiol 2024; 83:1579-1613. [PMID: 38493389 DOI: 10.1016/j.jacc.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2024]
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7
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Jneid H, Chikwe J, Arnold SV, Bonow RO, Bradley SM, Chen EP, Diekemper RL, Fugar S, Johnston DR, Kumbhani DJ, Mehran R, Misra A, Patel MR, Sweis RN, Szerlip M. 2024 ACC/AHA Clinical Performance and Quality Measures for Adults With Valvular and Structural Heart Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Performance Measures. Circ Cardiovasc Qual Outcomes 2024; 17:e000129. [PMID: 38484039 DOI: 10.1161/hcq.0000000000000129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/18/2024]
Affiliation(s)
- Hani Jneid
- ACC/AHA Joint Committee on Clinical Data Standards liaison
- Society for Cardiovascular Angiography and Interventions representative
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8
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De Azevedo D, Boute M, Tribouilloy C, Maréchaux S, Pouleur AC, Bohbot Y, Rusinaru D, Altes A, Thellier N, Beauloye C, Pasquet A, Gerber BL, de Kerchove L, Vanoverschelde JLJ, Vancraeynest D. Quantifying the Survival Loss Linked to Late Therapeutic Indication in High-Gradient Severe Aortic Stenosis. JACC. ADVANCES 2024; 3:100830. [PMID: 38938822 PMCID: PMC11198331 DOI: 10.1016/j.jacadv.2024.100830] [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: 09/25/2023] [Revised: 11/17/2023] [Accepted: 12/05/2023] [Indexed: 06/29/2024]
Abstract
Background International guidelines recommend aortic valve replacement (AVR) as Class I triggers in high-gradient severe aortic stenosis (HGSAS) patients with symptoms and/or left ventricular ejection fraction (LVEF) <50%. The association between waiting for these triggers and postoperative survival penalty is poorly studied. Objectives The purpose of this study was to examine the impact of guideline-based Class I triggers on long-term postoperative survival in HGSAS patients. Methods 2,030 patients operated for HGSAS were included and classified as follows: no Class I triggers (no symptoms and LVEF >50%, n = 853), symptoms with LVEF >50% (n = 965), or LVEF <50% regardless of symptoms (n = 212). Survival was compared after matching (inverse probability weighting) for clinical differences. Restricted mean survival time was analyzed to quantify lifetime loss. Results Ten-year survival was better without any Class I trigger than with symptoms or LVEF <50% (67.1% ± 3% vs 56.4% ± 3% vs 53.1% ± 7%, respectively, P < 0.001). Adjusted death risks increased significantly in operated patients with symptoms (HR: 1.45 [95% CI: 1.15-1.82]) or LVEF <50% (HR: 1.47 [95% CI: 1.05-2.06]) than in those without Class I triggers. Performing AVR with LVEF >60% produced similar outcomes to that of the general population, whereas operated patients with LVEF <60% was associated with a 10-year postoperative survival penalty. Furthermore, according to restricted mean survival time analyses, operating on symptomatic patients or with LVEF <60% led to 8.3- and 11.4-month survival losses, respectively, after 10 years, compared with operated asymptomatic patients with a LVEF >60%. Conclusions Guideline-based Class I triggers for AVR in HGSAS have profound consequences on long-term postoperative survival, suggesting that HGSAS patients should undergo AVR before trigger onset. Operating on patients with LVEF <60% is already associated with a 10-year postoperative survival penalty questioning the need for an EF threshold recommending AVR in HGSAS patients.
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Affiliation(s)
- David De Azevedo
- Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, and IREC/CARD UCLouvain, Brussels, Belgium
| | - Marin Boute
- Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, and IREC/CARD UCLouvain, Brussels, Belgium
| | - Christophe Tribouilloy
- Department of Cardiology, University Hospital Amiens, Amiens, France
- UR UPJV 7517, Jules Verne University of Picardie, Amiens, France
| | - Sylvestre Maréchaux
- Laboratoire ETHICS, Groupement des Hôpitaux de l’Institut Catholique de Lille, Service de cardiologie-USIC, Université Catholique de Lille, Lille, France
| | - Anne-Catherine Pouleur
- Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, and IREC/CARD UCLouvain, Brussels, Belgium
| | - Yohann Bohbot
- Department of Cardiology, University Hospital Amiens, Amiens, France
- UR UPJV 7517, Jules Verne University of Picardie, Amiens, France
| | - Dan Rusinaru
- Department of Cardiology, University Hospital Amiens, Amiens, France
- UR UPJV 7517, Jules Verne University of Picardie, Amiens, France
| | - Alexandre Altes
- Laboratoire ETHICS, Groupement des Hôpitaux de l’Institut Catholique de Lille, Service de cardiologie-USIC, Université Catholique de Lille, Lille, France
| | - Nicolas Thellier
- Laboratoire ETHICS, Groupement des Hôpitaux de l’Institut Catholique de Lille, Service de cardiologie-USIC, Université Catholique de Lille, Lille, France
| | - Christophe Beauloye
- Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, and IREC/CARD UCLouvain, Brussels, Belgium
| | - Agnès Pasquet
- Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, and IREC/CARD UCLouvain, Brussels, Belgium
| | - Bernhard L. Gerber
- Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, and IREC/CARD UCLouvain, Brussels, Belgium
| | - Laurent de Kerchove
- Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, and IREC/CARD UCLouvain, Brussels, Belgium
| | - Jean-Louis J. Vanoverschelde
- Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, and IREC/CARD UCLouvain, Brussels, Belgium
| | - David Vancraeynest
- Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, and IREC/CARD UCLouvain, Brussels, Belgium
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9
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Généreux P, Schwartz A, Oldemeyer B, Cohen DJ, Redfors B, Prince H, Zhao Y, Lindman BR, Pibarot P, Leon MB. Design and rationale of the evaluation of transcatheter aortic valve replacement compared to surveillance for patients with asymptomatic severe aortic stenosis: The EARLY TAVR trial. Am Heart J 2024; 268:94-103. [PMID: 38056546 DOI: 10.1016/j.ahj.2023.11.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND For patients with asymptomatic, severe aortic stenosis (AS) and preserved left ventricular ejection fraction, current guidelines recommend clinical surveillance every 6 to 12 months. To date, no randomized trials have examined whether an early intervention with transcatheter aortic valve replacement (TAVR) will improve outcomes among these patients. STUDY DESIGN AND OBJECTIVES EARLY TAVR is a prospective, randomized, controlled, and multicenter trial, with an event-based design. Asymptomatic severe AS patients (n = 900) are randomized 1:1 to either clinical surveillance or TAVR with the Edwards SAPIEN 3/SAPIEN 3 Ultra transcatheter heart valve. Patients are stratified by whether they are able to perform a treadmill stress test. The primary end point is death, stroke, or unplanned cardiovascular hospitalization. Patients who are asymptomatic but have a positive stress test will be followed in a registry and undergo aortic valve replacement as per current guidelines. CONCLUSIONS EARLY TAVR is the largest randomized trial to date assessing the role of early intervention among patients with asymptomatic severe AS compared to clinical surveillance and the first to study the role of TAVR. TRIAL REGISTRATION NUMBER NCT03042104.
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Affiliation(s)
- Philippe Généreux
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ.
| | - Allan Schwartz
- Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, NY
| | | | - David J Cohen
- Cardiovascular Research Foundation, New York, NY; St. Francis Hospital and Heart Center, Roslyn, NY
| | - Björn Redfors
- Cardiovascular Research Foundation, New York, NY; Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | | | | | | | - Philippe Pibarot
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Martin B Leon
- Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, NY; Cardiovascular Research Foundation, New York, NY
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10
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Senguttuvan NB, Srinivasan NV, Panchanatham M, Abdulkader RS, Anandaram A, Polareddy DR, Ramesh S, Singh H, Yallanki H, Kaliyamoorthi D, Chidambaram S, Ramalingam V, Rajendran R, Muralidharan TR, Rao R, Seth A, Claessen B, Krishnamoorthy P. Systematic review and meta-analysis of early aortic valve replacement versus conservative therapy in patients with asymptomatic aortic valve stenosis with preserved left ventricle systolic function. Open Heart 2024; 11:e002511. [PMID: 38191233 PMCID: PMC10806528 DOI: 10.1136/openhrt-2023-002511] [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: 10/06/2023] [Accepted: 12/14/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND A quarter of patients with severe aortic stenosis (AS) were asymptomatic, and only a third of them survived at the end of 4 years. Only a select subset of these patients was recommended for aortic valve replacement (AVR) by the current American College of Cardiology/American Heart Association guidelines. We intended to study the effect of early AVR (eAVR) in this subset of asymptomatic patients with preserved left ventricle function. METHODS AND RESULTS We searched PubMed and Embase for randomised and observational studies comparing the effect of eAVR versus conservative therapy in patients with severe, asymptomatic AS and normal left ventricular function. The primary outcome was all-cause mortality. The secondary outcomes were composite major adverse cardiac events (MACE) (study defined), myocardial infarction (MI), stroke, cardiac death, sudden death, the development of symptoms, heart failure hospitalisations and major bleeding. We used GRADEPro to assess the certainty of the evidence. In the randomised controlled trial (RCT) only analysis, we found no significant difference in all-cause mortality between the early aortic intervention group versus the conservative arm (CA) (incidence rate ratio, IRR (CI): 0.5 (0.2 to 1.1), I2=31%, p=0.09). However, in the overall cohort, we found mortality benefit for eAVR over CA (IRR (CI): 0.4 (0.3 to 0.7), I2=84%, p<0.01). There were significantly lower MACE, cardiac death, sudden death, development of symptoms and heart failure hospitalisations in the eAVR group. We noticed no difference in MI, stroke and major bleeding. CONCLUSION We conclude that there is no reduction in all-cause mortality in the eAVR arm in patients with asymptomatic AS with preserved ejection fraction. However, eAVR reduces heart failure related hospitalisations and death or heart failure hospitalisations. PROSPERO REGISTRATION NUMBER CRD42022306132.
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Affiliation(s)
| | | | - Manokar Panchanatham
- Department of Cardiology, SRIHER (Deemed to be University), Chennai, Tamil Nadu, India
| | | | - Asuwin Anandaram
- Department of Clinical Research, SRIHER (Deemed to be University), Chennai, Tamil Nadu, India
| | | | - Sankaran Ramesh
- Department of Cardiology, SRIHER (Deemed to be University), Chennai, Tamil Nadu, India
| | - Harsimran Singh
- Department of Cardiology, SRIHER (Deemed to be University), Chennai, Tamil Nadu, India
| | - Hanumath Yallanki
- Department of Medicine, SRIHER (Deemed to be University), Chennai, Tamil Nadu, India
| | | | | | - Vadivelu Ramalingam
- Department of Cardiology, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India
| | | | | | - Ravindar Rao
- Department of Cardiology, Rajasthan University of Health Sciences, Jaipur, Rajasthan, India
| | - Ashok Seth
- Department of Cardiology, Fortis Escorts Heart Institute and Research Centre, New Delhi, Delhi, India
| | - Bimmer Claessen
- Department of Cardiology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Parasuram Krishnamoorthy
- Cardiology, Icahn School of Medicine at Mount Sinai Zena and Michael A Wiener Cardiovascular Institute, New York, New York, USA
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11
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Choi Y, Ahn JM, Yang DH, Koo HJ, Lee SA, Kang DY, Kim JB, Park DW, Kim DH, Choo SJ, Park SJ. Clinical outcomes after aortic valve replacement with severe stenosis of trileaflet aortic valve and low valve calcium score. Heart 2023; 109:1479-1485. [PMID: 37290900 DOI: 10.1136/heartjnl-2023-322435] [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: 01/26/2023] [Accepted: 05/22/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Some patients have severe aortic valve stenosis (AS) despite a lower degree of aortic valve calcification (AVC). This study compared the clinical features and prognosis of patients undergoing aortic valve replacement (AVR) for severe AS with a low AVC score compared with those with higher AVC scores. METHODS This study included 1002 Korean patients with symptomatic severe degenerative AS who underwent AVR. We measured AVC score before AVR and defined low AVC as AVC score of <2000 units for male patients and <1300 units for female patients. Patients with bicuspid or rheumatic aortic valve disease were excluded. RESULTS The mean age was 75.6±7.9 years and 487 patients (48.6%) were female. Mean left ventricular ejection fraction was 59.4%±10.4%, and concomitant coronary revascularisation was performed in 96 patients (9.6%). The median aortic valve calcium score was 3122 units (IQR 2249-4289 units) among male patients and 1756 units (IQR 1192-2572) among female patients. A total of 242 patients (24.2%) had low AVC; they were significantly younger (73.5±8.7 years vs 76.3±7.5 years, p<0.001) and were more likely to be female (59.5% vs 45.1%, p<0.001) and on haemodialysis (5.4% vs 1.8%, p=0.006) than those with high AVC. During a follow-up (median: 3.8 years), the patients with low AVC had significantly higher risk of death from any cause (adjusted HR 1.60, 95% CI 1.02 to 2.52, p=0.04), mostly non-cardiac cause. CONCLUSIONS Patients with low AVC exhibit distinct clinical characteristics and a higher risk of long-term mortality compared with those with high AVC.
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Affiliation(s)
- Yeonwoo Choi
- Division of Cardiology, Asan Medical Center, Seoul, South Korea
| | - Jung-Min Ahn
- Division of Cardiology, Asan Medical Center, Seoul, South Korea
| | - Dong Hyun Yang
- Department of Radiology, Asan Medical Center, Seoul, South Korea
| | - Hyun Jung Koo
- Department of Radiology, Asan Medical Center, Seoul, South Korea
| | - Seung-Ah Lee
- Division of Cardiology, Asan Medical Center, Seoul, South Korea
| | - Do-Yoon Kang
- Division of Cardiology, Asan Medical Center, Seoul, South Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Seoul, South Korea
| | - Duk-Woo Park
- Division of Cardiology, Asan Medical Center, Seoul, South Korea
| | - Dae-Hee Kim
- Division of Cardiology, Asan Medical Center, Seoul, South Korea
| | - Suk Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Seoul, South Korea
| | - Seung-Jung Park
- Division of Cardiology, Asan Medical Center, Seoul, South Korea
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12
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Kobayashi Y, Izumo M, Okuyama K, Uenomachi N, Shoji T, Kai T, Okuno T, Sato Y, Kuwata S, Koga M, Ishibashi Y, Tanabe Y, Miyairi T, Akashi YJ. Feasibility of Transcatheter Aortic Valve Implantation in Patients With Very Severe Aortic Stenosis. Circ Rep 2023; 5:358-364. [PMID: 37693232 PMCID: PMC10483111 DOI: 10.1253/circrep.cr-23-0063] [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: 07/11/2023] [Accepted: 07/11/2023] [Indexed: 09/12/2023] Open
Abstract
Background: Very severe aortic stenosis (AS) has a poor prognosis even in asymptomatic patients, and asymptomatic very severe AS is a Class IIa indication for aortic valve replacement, although the safety and effectiveness of transcatheter aortic valve implantation (TAVI) for very severe AS is not well-established. Methods and Results: This study included 366 patients undergoing TAVI at a single center, with 85 and 281 patients in the very severe AS (peak velocity ≥5 m/s or mean pressure gradient (PG) ≥60 mmHg) and severe AS groups, respectively. Procedural and clinical outcomes at 1-year follow-up were compared between groups. The calcium scores were significantly higher in the very severe AS group (2,864.5 vs. 1,405.8 arbitrary units [AU] (P<0.001). Although the patient-prosthesis mismatch rate was higher in the very severe AS group (38.3% vs. 25.7%; P=0.029), there was no significant difference in the early safety and clinical efficacy between the groups (16.5% vs. 17.1% and 12.0% vs. 18.9%, respectively). Similarly, there was no significant difference in all-cause mortality at 1 year (4.8% vs. 9.8%). Conclusions: Despite a higher incidence of prosthesis-patient mismatch in those with very severe AS, the procedural and clinical outcomes were comparable to those in patients with severe AS. TAVI may be a reasonable treatment option for very severe AS.
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Affiliation(s)
- Yoshikuni Kobayashi
- Department of Cardiology, St. Marianna University School of Medicine Kawasaki Japan
| | - Masaki Izumo
- Department of Cardiology, St. Marianna University School of Medicine Kawasaki Japan
| | - Kazuaki Okuyama
- Department of Cardiology, St. Marianna University School of Medicine Kawasaki Japan
| | - Nina Uenomachi
- Ultrasound Center, St. Marianna University School of Medicine Kawasaki Japan
| | - Tatsuro Shoji
- Department of Cardiology, St. Marianna University School of Medicine Kawasaki Japan
| | - Takahiko Kai
- Department of Cardiology, St. Marianna University School of Medicine Kawasaki Japan
| | - Taishi Okuno
- Department of Cardiology, St. Marianna University School of Medicine Kawasaki Japan
| | - Yukio Sato
- Department of Cardiology, St. Marianna University School of Medicine Kawasaki Japan
| | - Shingo Kuwata
- Department of Cardiology, St. Marianna University School of Medicine Kawasaki Japan
| | - Masashi Koga
- Department of Cardiology, St. Marianna University School of Medicine Kawasaki Japan
| | - Yuki Ishibashi
- Department of Cardiology, St. Marianna University School of Medicine Kawasaki Japan
| | - Yasuhiro Tanabe
- Department of Cardiology, St. Marianna University School of Medicine Kawasaki Japan
| | - Takeshi Miyairi
- Department of Cardiovascular Surgery, St. Marianna University School of Medicine Kawasaki Japan
| | - Yoshihiro J Akashi
- Department of Cardiology, St. Marianna University School of Medicine Kawasaki Japan
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13
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Banovic M, Iung B, Wojakowski W, Van Mieghem N, Bartunek J. Asymptomatic Severe and Moderate Aortic Stenosis: Time for Appraisal of Treatment Indications. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2023; 7:100201. [PMID: 37745683 PMCID: PMC10512009 DOI: 10.1016/j.shj.2023.100201] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 04/11/2023] [Accepted: 04/13/2023] [Indexed: 09/26/2023]
Abstract
Over the last decades, we have witnessed considerable improvements in diagnostics and risk stratification of patients with significant aortic stenosis (AS), paralleled by advances in operative and anesthetic techniques. In addition, accumulating evidence points to the potential benefit of early valve replacement in such patients prior to the onset of symptoms. In parallel, interventional randomized trials have proven the benefit of transcatheter aortic valve replacement in comparison to a surgical approach to valve replacement over a broad risk spectrum in symptomatic patients with AS. This article reviews contemporary management approaches and scrutinizes open questions regarding timing and mode of intervention in asymptomatic patients with severe AS. We also discuss the challenges surrounding the management of symptomatic patients with moderate AS as well as emerging dilemmas related to the concept of a life-long treatment strategy for patients with AS.
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Affiliation(s)
- Marko Banovic
- Belgrade Medical Faculty, University of Belgrade, Belgrade, Serbia
- Cardiology Department, University Clinical Center of Serbia, Belgrade, Serbia
| | - Bernard Iung
- University of Paris, Paris, France
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris (AP-HP), Bichat Hospital, Paris, France
| | - Wojtek Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | | | - Jozef Bartunek
- Cardiovascular Center Aalst, OLV Hospital, Aalst, Belgium
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14
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Manzo R, Ilardi F, Nappa D, Mariani A, Angellotti D, Immobile Molaro M, Sgherzi G, Castiello DS, Simonetti F, Santoro C, Canonico ME, Avvedimento M, Piccolo R, Franzone A, Esposito G. Echocardiographic Evaluation of Aortic Stenosis: A Comprehensive Review. Diagnostics (Basel) 2023; 13:2527. [PMID: 37568890 PMCID: PMC10417789 DOI: 10.3390/diagnostics13152527] [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: 06/26/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
Echocardiography represents the most important diagnostic tool in the evaluation of aortic stenosis. The echocardiographic assessment of its severity should always be performed through a standardized and stepwise approach in order to achieve a comprehensive evaluation. The latest technical innovations in the field of echocardiography have improved diagnostic accuracy, guaranteeing a better and more detailed evaluation of aortic valve anatomy. An early diagnosis is of utmost importance since it shortens treatment delays and improves patient outcomes. Echocardiography plays a key role also in the evaluation of all the structural changes related to aortic stenosis. Detailed evaluation of subtle and subclinical changes in left ventricle function has a prognostic significance: scientific efforts have been addressed to identify the most accurate global longitudinal strain cut-off value able to predict adverse outcomes. Moreover, in recent years the role of artificial intelligence is increasingly emerging as a promising tool able to assist cardiologists in aortic stenosis screening and diagnosis, especially by reducing the rate of aortic stenosis misdiagnosis.
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Affiliation(s)
| | - Federica Ilardi
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, 80131 Naples, Italy
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15
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Abstract
Patients with chronic kidney disease (CKD) exhibit tremendously elevated risk for cardiovascular disease, particularly ischemic heart disease, due to premature vascular and cardiac aging and accelerated ectopic calcification. The presence of cardiovascular calcification associates with increased risk in patients with CKD. Disturbed mineral homeostasis and diverse comorbidities in these patients drive increased systemic cardiovascular calcification in different manifestations with diverse clinical consequences, like plaque instability, vessel stiffening, and aortic stenosis. This review outlines the heterogeneity in calcification patterning, including mineral type and location and potential implications on clinical outcomes. The advent of therapeutics currently in clinical trials may reduce CKD-associated morbidity. Development of therapeutics for cardiovascular calcification begins with the premise that less mineral is better. While restoring diseased tissues to a noncalcified homeostasis remains the ultimate goal, in some cases, calcific mineral may play a protective role, such as in atherosclerotic plaques. Therefore, developing treatments for ectopic calcification may require a nuanced approach that considers individual patient risk factors. Here, we discuss the most common cardiac and vascular calcification pathologies observed in CKD, how mineral in these tissues affects function, and the potential outcomes and considerations for therapeutic strategies that seek to disrupt the nucleation and growth of mineral. Finally, we discuss future patient-specific considerations for treating cardiac and vascular calcification in patients with CKD-a population in need of anticalcification therapies.
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Affiliation(s)
- Joshua D. Hutcheson
- Department of Biomedical Engineering, Florida International University, Miami, FL (J.D.H.)
| | - Claudia Goettsch
- Department of Internal Medicine I, Division of Cardiology, Medical Faculty, RWTH Aachen University, Germany (C.G.)
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16
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Yasmin F, Shaikh A, Asghar MS, Moeed A, Najeeb H, Waqar E, Ram MD, Nankani A, Ochani RK, Aamir M, Ullah W, Waqar F, Johnson DM, Johnson DM. Early Transcatheter or Surgical Aortic Valve Replacement Versus Conservative Management in Asymptomatic Patients With Severe Aortic Stenosis: A Systematic Review and Meta-analysis. Curr Probl Cardiol 2023; 48:101477. [PMID: 36328337 DOI: 10.1016/j.cpcardiol.2022.101477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 10/26/2022] [Indexed: 02/01/2023]
Abstract
The merits of conservative management vs early intervention in patients with asymptomatic severe aortic stenosis remains unknown. Digital databases (MEDLINE, Google Scholar, and Embase) were searched for all relevant studies from inception through September 2022. Studies comparing conservative management with early intervention were compared using a random-effects model to calculate risk ratios (RRs) with 95% confidence interval (CI). A total of 12 studies comprising 3624 asymptomatic aortic stenosis patients (1747 receiving surgery, and 1877 receiving conservative treatment) were included in the analysis. The average follow-up time was 4.45 (IQR 3.5-5) years. Early intervention was associated with a significantly reduced risk of cardiac (RR 0.42, 95% CI 0.25-0.72; P = 0.001; I2 = 54%), non-cardiac (RR 0.46, 95% CI 0.32-0.68; P < 0.0001; I2 = 0%), all-cause mortality (RR 0.40, 95% CI 0.32-0.51; P < 0.00001; I2 = 58%), heart failure hospitalization (RR 0.21, 95% CI 0.13-0.36; P < 0.00001; I2 = 0%), sudden cardiac death (RR 0.29, 95% CI 0.12-0.66; P = 0.004, I2 = 24%), and MACE (RR 0.46, 95% CI; 0.28-0.75; P = 0.002; I2 = 68%), compared with conservative management. There was no significant difference in the 30-day mortality (RR 0.63, 95% CI 0.19-2.04; P = 0.44; I2 = 28%), myocardial infarction (RR 0.44, 95% CI 0.19-1.06; P = 0.07, I2=0%), and 90-day mortality (RR 0.68, 95% CI 0.20-2.37; P = 0.55; I2 = 61%) between the 2 groups. This meta-analysis shows statistically significant reductions in the risk for all-cause mortality, cardiac specific mortality, non-cardiac mortality, heart failure hospitalization, MACE, and sudden cardiac death among asymptomatic aortic stenosis patients who underwent early intervention as opposed to conservative management.
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Affiliation(s)
- Farah Yasmin
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Asim Shaikh
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | | | - Abdul Moeed
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Hala Najeeb
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Eisha Waqar
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Muskaan Doulat Ram
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Avinash Nankani
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Rohan Kumar Ochani
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Muhammad Aamir
- Lehigh Valley Heart Specialists, Lehigh Valley Health Network, Allentown PA
| | - Waqas Ullah
- Division of Cardiology, Sidney Kimmel Medical College, Thomas Jefferson University Hospitals, Philadelphia PA
| | - Fahad Waqar
- Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Drew M Johnson
- Division of Cardiology, Sidney Kimmel Medical College, Thomas Jefferson University Hospitals, Philadelphia PA.
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17
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Aziminia N, Nitsche C, Mravljak R, Bennett J, Thornton GD, Treibel TA. Heart failure and excess mortality after aortic valve replacement in aortic stenosis. Expert Rev Cardiovasc Ther 2023; 21:193-210. [PMID: 36877090 PMCID: PMC10069375 DOI: 10.1080/14779072.2023.2186853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/28/2023] [Indexed: 03/07/2023]
Abstract
INTRODUCTION In aortic stenosis (AS), the heart transitions from adaptive compensation to an AS cardiomyopathy and eventually leads to decompensation with heart failure. Better understanding of the underpinning pathophysiological mechanisms is required in order to inform strategies to prevent decompensation. AREAS COVERED In this review, we therefore aim to appraise the current pathophysiological understanding of adaptive and maladaptive processes in AS, appraise potential avenues of adjunctive therapy before or after AVR and highlight areas of further research in the management of heart failure post AVR. EXPERT OPINION Tailored strategies for the timing of intervention accounting for individual patient's response to the afterload insult are underway, and promise to guide better management in the future. Further clinical trials of adjunctive pharmacological and device therapy to either cardioprotect prior to intervention or promote reverse remodeling and recovery after intervention are needed to mitigate the risk of heart failure and excess mortality.
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Affiliation(s)
- Nikoo Aziminia
- Institute of Cardiovascular Science, University College London, London, England
- Barts Heart Centre, London, England
| | - Christian Nitsche
- Institute of Cardiovascular Science, University College London, London, England
- Barts Heart Centre, London, England
| | | | - Jonathan Bennett
- Institute of Cardiovascular Science, University College London, London, England
- Barts Heart Centre, London, England
| | - George D Thornton
- Institute of Cardiovascular Science, University College London, London, England
- Barts Heart Centre, London, England
| | - Thomas A Treibel
- Institute of Cardiovascular Science, University College London, London, England
- Barts Heart Centre, London, England
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18
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Kim HR, Kim WK, Kim HJ, Kim JB, Jung SH, Choo SJ, Chung CH, Lee JW. The fate of aortic valve after rheumatic mitral valve surgery. J Thorac Cardiovasc Surg 2023; 165:622-629.e2. [PMID: 33867129 DOI: 10.1016/j.jtcvs.2021.03.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 02/24/2021] [Accepted: 03/08/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Deterioration of the native aortic valve function by a late progression of rheumatic disease is not infrequent in patients who underwent rheumatic mitral valve surgery; however, this phenomenon has not been clearly quantified. METHODS A total of 1155 consecutive patients (age 52.0 ± 12.9 years; 807 female) who underwent rheumatic mitral valve surgery without concomitant aortic valve surgery from 1997 to 2015 were enrolled. The primary end point was the composite of progression to severe aortic valve dysfunction or a requirement of subsequent aortic valve replacements during follow-up. To determine the risk factors of the primary outcome, we performed the generalized linear mixed model. RESULTS The baseline severities of aortic valve were none to trivial in 880 patients (76.2%), mild in 256 patients (22.2%), and moderate in 19 patients (1.6%). The latest 1062 echocardiographic assessments (91.9%; median, 81.2 postoperative months; interquartile range, 37.3-132.1 months) demonstrated 26 cases (0.33%/patient-year) meeting the primary end point during follow-up. Cumulative incidence of the primary end point at 10 years was 0.4% ± 0.3% and 7.4% ± 2.5% depending on the presence of mild or greater aortic valve dysfunction at baseline (P < .01). In multivariable analyses, aortic valve peak pressure gradient (odds ratio, 1.14; 95% confidence interval, 1.10-1.20), aortic regurgitation degree (mild over none: odds ratio, 3.26; 95% confidence interval, 1.15-9.23), and time (odds ratio, 1.30; 95% confidence interval 1.19-1.41) were significantly associated with the occurrence of the primary end point. CONCLUSIONS Progression of severe aortic valve dysfunction and the need for aortic valve replacement are uncommon in patients undergoing rheumatic mitral valve surgery. However, such events were relatively common among those with mild or greater aortic valve dysfunction at the time of mitral valve surgery.
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Affiliation(s)
- Hong Rae Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Wan Kee Kim
- Department of Thoracic and Cardiovascular Surgery, Yongin Severance Hospital, Gyeonggi-do, Republic of Korea
| | - Ho Jin Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea.
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Suk Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Cheol Hyun Chung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Jae Won Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
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19
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Costa GNF, Cardoso JFL, Oliveiros B, Gonçalves L, Teixeira R. Early surgical intervention versus conservative management of asymptomatic severe aortic stenosis: a systematic review and meta-analysis. Heart 2023; 109:314-321. [PMID: 36198484 DOI: 10.1136/heartjnl-2022-321411] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 09/26/2022] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE Timing of intervention for patients with asymptomatic severe aortic stenosis (AS) remains controversial. To compare the outcomes of early aortic valve replacement (AVR) versus watchful waiting (WW) in patients with asymptomatic severe AS. METHODS We systematically searched PubMed, Embase and Cochrane databases, in December 2021, for studies comparing early AVR with WW in the treatment of asymptomatic severe AS. Random-effects meta-analysis was performed. RESULTS Twelve studies were included in which two were randomised clinical trials. A total of 4130 patients were included, providing a 1092 pooled death events. Our meta-analysis showed a significantly lower all-cause mortality for the early AVR compared with WW group, although with a high amount of heterogeneity between studies in the magnitude of the effect (pooled OR 0.40; 95% CI 0.35 to 0.45, p<0.01; I²=61%). An early surgery strategy displayed a significantly lower cardiovascular mortality (pooled OR 0.33; 95% CI 0.19 to 0.56, p<0.01; I²=64%) and heart failure hospitalisation (pooled OR 0.19; 95% CI 0.10 to 0.39, p<0.01, I²=7%). However, both groups had similar rates of stroke (pooled OR 1.30; 95% CI 0.73 to 2.29, p=0.36, I²=0%) and myocardial infarction (pooled OR 0.49; 95% CI 0.19 to 1.27, p=0.14, I²= 0%). CONCLUSIONS This study suggests that for patients with asymptomatic severe AS an early surgical intervention compared with a conservative WW strategy was associated with a lower heart failure hospitalisation and a similar rate of stroke or myocardial infarction, although with significant risk of bias. PROSPERO REGISTRATION NUMBER CRD42021291144.
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Affiliation(s)
- Gonçalo Nuno Ferraz Costa
- Serviço de Cardiologia, Centro Hospitalar e Universitario de Coimbra, Coimbra, Portugal .,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | | | | | - Lino Gonçalves
- Serviço de Cardiologia, Centro Hospitalar e Universitario de Coimbra, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Rogerio Teixeira
- Serviço de Cardiologia, Centro Hospitalar e Universitario de Coimbra, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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20
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Basmadjian L, Bouabdallaoui N, Simard F, O'Meara E, Ducharme A, Rouleau JL, Racine N, White M, Sirois MG, Asgar A, Ibrahim R, Dorval JF, Bonan R, Cartier R, Forcillo J, El-Hamamsy I, Henri C. Growth Differentiation Factor-15 as a Predictor of Functional Capacity, Frailty, and Ventricular Dysfunction in Patients With Aortic Stenosis and Preserved Left Ventricular Ejection Fraction. Am J Cardiol 2023; 186:11-16. [PMID: 36334433 DOI: 10.1016/j.amjcard.2022.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/25/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022]
Abstract
In aortic stenosis (AS), left ventricular (LV) remodeling often occurs before symptom onset, and early intervention may be beneficial. Risk stratification remains challenging and identification of biomarkers may be useful. We evaluated the association between growth differentiation factor-15 (GDF-15) and soluble suppression of tumorigenicity 2 (sST2) and known markers of poor prognosis in AS. Baseline plasma GDF-15 and sST2 levels were measured in 70 patients with moderate-severe AS (aortic valve area <1.5 cm2) and preserved LV ejection fraction (>45%). Patients were categorized into "low GDF-15" versus "high GDF-15" and "low sST2" versus "high sST2" groups. Groups were compared for differences in cardiovascular risk factors, 6-minute walk test, 5 m gait speed, cognitive function (Montreal Cognitive Assessment), and echocardiographic parameters. Overall, 44% of patients were deemed asymptomatic by New York Heart Association class, 61% had severe AS (aortic valve area <1 cm2) and all patients had preserved LV ejection fraction. GDF-15 levels were not predictive of AS severity. However, high GDF-15 (>1,050 pg/ml) was associated with LV dysfunction as shown by lower indexed stroke volume (p <0.01), worse LV global longitudinal strain (p = 0.04), greater mean E/e' (p = 0.02) and indexed left atrial volume (p <0.01). It was also associated with decreased functional capacity with shorter 6-minute walk test (p = 0.01) and slower 5 m gait speed (p = 0.02). Associations between sST2 levels and markers of poor prognosis were less compelling. In this study of patients with moderate to severe AS, elevated GDF-15 levels are associated with impaired functional capacity, poorer performance on fragility testing, and LV dysfunction. In conclusion, GDF-15 may integrate these markers of adverse outcomes into a single biomarker of poor prognosis.
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Affiliation(s)
- Lauren Basmadjian
- Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Nadia Bouabdallaoui
- Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - François Simard
- Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Eileen O'Meara
- Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Anique Ducharme
- Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Jean-Lucien Rouleau
- Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Normand Racine
- Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Michel White
- Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Martin G Sirois
- Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Anita Asgar
- Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Reda Ibrahim
- Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Jean-François Dorval
- Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Raoul Bonan
- Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Raymond Cartier
- Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Jessica Forcillo
- Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Ismail El-Hamamsy
- Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Christine Henri
- Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
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21
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Jaiswal V, Khan N, Jaiswal A, Dagar M, Joshi A, Huang H, Naz H, Attia AM, Ghanim M, Baburaj A, Song D. Early surgery vs conservative management among asymptomatic aortic stenosis: A systematic review and meta-analysis. IJC HEART & VASCULATURE 2022; 43:101125. [PMID: 36176308 PMCID: PMC9513172 DOI: 10.1016/j.ijcha.2022.101125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/31/2022] [Accepted: 09/17/2022] [Indexed: 11/20/2022]
Abstract
Introduction Although aortic valve replacement in severe symptomatic Aortic Stenosis (AS) are clearly outlined, the role of surgical intervention in asymptomatic severe AS remains unclear with limited evidence. The aim of our meta-analysis is to evaluate the efficacy and safety of early surgical aortic valve repair compared to conservative management. Methods A systematic literature search was performed in PubMed, Scopus, Embase and Cochrane databases for studies comparing the early surgery versus conservative management among asymptomatic aortic stenosis patients. Unadjusted odds ratios (OR) were pooled using a random-effect model, and a p-value of < 0.05 was considered statistically significant. Results A total of 5 articles (3 observational studies and 2 randomized controlled trials) were included. At a median followup of 4.1 years, here were significantly lower odds of all-cause mortality [OR = 0.30 (95 %CI:0.17-0.53), p < 0.0001], cardiovascular mortality [OR = 0.35 (95 %CI:(0.17-0.72), p = 0.005], and sudden cardiac death (OR = 0.36 (95 %CI: 0.15-0.89), p = 0.03) among early surgery group compared with conservative care. There was no significant difference between incidence of major bleeding, clinical thromboembolic events, hospitalization due to heart failure, stroke and myocardial infarction between the conservative care groups and early surgery. Conclusion Among asymptomatic patients with AS, early surgery shows better outcomes in reducing all-cause mortality and cardiovascular mortality compared with conservative management approaches.
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Affiliation(s)
- Vikash Jaiswal
- Department of Cardiovascular Research, Larkin Community Hospital, FL, USA
| | - Nida Khan
- Jinnah Sindh Medical University, Karachi, Pakistan
| | - Akash Jaiswal
- Department of Geriatric Medicine, All India Institute of Medical Science, New Delhi, India
| | - Mehak Dagar
- Himalayan Institute of Medical Science, Dehradun, India
| | - Amey Joshi
- Department of Cardiovascular Research, Larkin Community Hospital, FL, USA
| | - Helen Huang
- University of Medicine and Health Science, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Hira Naz
- Fatima Jinnah Medical University, Pakistan
| | | | | | - Abiram Baburaj
- Center for Public Health, Queen’s University Belfast, UK
| | - David Song
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai – Elmhurst Hospital Center, NY, USA
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22
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Banovic M, Rajani R. Do all patients with asymptomatic severe aortic stenosis need treatment? Expert Rev Cardiovasc Ther 2022; 20:787-793. [PMID: 36243000 DOI: 10.1080/14779072.2022.2137491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
INTRODUCTION Although guidelines recommend a watchful waiting strategy for patients with asymptomatic severe aortic stenosis, there have been considerable advancements in surgical and anaesthetic techniques along with the success of transcatheter aortic valve replacement (AVR) as a viable alternative to surgical AVR. Inevitably, these developments have raised questions as to whether or not there is still merit in waiting for symptoms to ensue before treatment may offered to these patients. AREA COVERED The principal purpose of this paper is to review the data supporting earlier intervention in patients with asymptomatic severe aortic stenosis, and to project the implications these and other ongoing trials will have on indications for AVR in asymptomatic patients in the future. EXPERT OPINION The threshold for intervention in certain subgroups of asymptomatic patients with severe AS has already been lowered. The next frontier will inevitably be determining whether all patients with severe AS should undergo AVR irrespective of their symptomatic status.
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Affiliation(s)
- Marko Banovic
- University Clinical Center of Serbia, Belgrade, Serbia.,Belgrade Medical Faculty, Belgrade, Serbia
| | - Ronak Rajani
- Cardiovascular Directorate, Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Biomedical Engineering and Imaging Sciences, King's College London, UK
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23
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Luthra S, Leiva-Juarez MM, Malvindi PG, Navaratanaraja M, Curzen N, Ohri SK. Reconsidered surgical aortic valve replacement after declined transcatheter valve implantation. Asian Cardiovasc Thorac Ann 2022; 30:1001-1009. [PMID: 36210789 DOI: 10.1177/02184923221132202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Outcomes for high surgical risk patients who declined transcatheter aortic valve implantation (TAVI) and then reconsidered for conventional aortic valve replacement (rSAVR) for severe calcific aortic stenosis are not well known. METHODS This single-centre, case-control study (rSAVR vs Conservative group) retrospectively analysed patients for rSAVR (2009-2019). Multivariable logistic regression was used to identify independent predictors of composite of neurological sequelae/renal failure/deep sternal wound infection/re-exploration and death. Survival was compared using Kaplan-Meier curves and log-rank test. A Cox proportional hazards model was used to determine predictors of survival. RESULTS TAVI was denied in 519/1095 patients, 114(10.4%) had rSAVR (cases) and 405 (37%) were managed conservatively (controls). Mean age for rSAVR was 80 years (IQR: 73.5-85 years). The commonest reason for declining TAVI was prohibitive high risk due to multiple comorbidities. Among rSAVR, hospital mortality was 2.2% and stroke was 4.4%. Median follow-up was conservative; 14.4 months versus rSAVR; 34.8 months. Five-year survival was conservative; 12.6% versus rSAVR; and 59.5% (overall conservative; 38.0% vs. rSAVR; 60.5%, p < 0.001). rSAVR was protective (hazard ratio [HR]: 0.37, 95% confidence interval [CI]: 0.26, 0.51, p < 0.001) and high comorbidities had high hazard (HR: 1.57, 95% CI: 1.19, 2.07, p = 0.001). rSAVR had fewer hospital readmission episodes (Conservative; 13.6/patient-year vs. rSAVR; 6.9/patient-year, p = 0.002). CONCLUSIONS rSAVR may be considered in high surgical risk elderly patients who have been declined TAVI in centres with low operative mortality. rSAVR may be superior to conservative management in carefully selected patients.
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Affiliation(s)
- Suvitesh Luthra
- Wessex Cardiothoracic Centre, Division of Cardiac Surgery, 7425Southampton University Hospital NHS Trust, Southampton, UK.,Academic Department of Human Development and Health, 7423University of Southampton, Southampton, UK
| | | | - Pietro G Malvindi
- Cardiac Surgery Unit, Azienda Ospedaliero Universitaria, Ancona, Italy
| | - Manoraj Navaratanaraja
- Wessex Cardiothoracic Centre, Division of Cardiac Surgery, 7425Southampton University Hospital NHS Trust, Southampton, UK
| | - Nick Curzen
- Wessex Cardiothoracic Centre, Division of Cardiology, Southampton University Hospital NHS Trust, Southampton, UK
| | - Sunil K Ohri
- Wessex Cardiothoracic Centre, Division of Cardiac Surgery, 7425Southampton University Hospital NHS Trust, Southampton, UK.,Academic Department of Human Development and Health, 7423University of Southampton, Southampton, UK
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24
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Identification of HIBCH as a Fatty Acid Metabolism-Related Biomarker in Aortic Valve Calcification Using Bioinformatics. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022. [DOI: 10.1155/2022/9558713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective. To identify fatty acid metabolism-related biomarkers of aortic valve calcification (AVC) using bioinformatics and to research the role of immune cell infiltration for AVC. Methods. The AVC dataset was retrieved from the Gene Expression Omnibus database. R package is used for differential expression genes analysis and weighted gene coexpression analysis. The differentially coexpressed genes were identified by the Venn diagram, followed by Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses of differentially coexpressed genes. Functions closely related to AVC were identified by GO and KEGG enrichment analyses of differentially coexpressed genes. Genes related to fatty acid metabolism were retrieved from the Molecular Signatures Database (MSigDB) database. After removing duplicate genes, least absolute shrinkage and selection operator (LASSO) regression analysis, support vector machine recursive feature elimination (SVM-RFE), and random forest were applied to recognize biomarkers related to fatty acid metabolism in AVC. The CIBERSORT tool was used to analyze infiltration of immune cells in normal and AVC samples. Correlations between biomarkers and immune cells were calculated. Finally, HIBCH-related pathway was predicted by single-gene gene set enrichment analysis (GSEA). Results. 2416 differentially expressed genes and one coexpression module were identified. A total of 1473 differentially coexpressed genes were acquired. GO and KEGG enrichment analyses demonstrated that differentially coexpressed genes were closely related to fatty acid metabolism. LASSO regression analysis, SVM-REF, and random forest revealed that 3-hydroxyisobutyryl-CoA hydrolase (HIBCH) was a biomarker of fatty acid metabolism-related genes in AVC. Significant high levels of memory B cells were found in AVC than normal samples, while activated natural killer (NK) cells were significantly low in AVC than normal samples. A significantly positive relevance was observed between HIBCH and activated NK cells, regulatory T cells, monocytes, naïve B cells, activated dendritic cells, resting memory CD4 T cells, resting NK cells, and CD8 T cells. A significantly negative relevance was observed between HIBCH and activated memory CD4 T cells, memory B cells, neutrophils, gamma delta T cells, M0 macrophages, and plasma cells. The single-gene GSEA results suggest that HIBCH may work through the inhibition of multiple immune-related pathways. Conclusion. HIBCH is closely relevant to immune cell infiltration in AVC and could be applied as a diagnostic marker for AVC.
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25
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Acute Decompensated Aortic Stenosis: State of the Art Review. Curr Probl Cardiol 2022; 48:101422. [PMID: 36167225 DOI: 10.1016/j.cpcardiol.2022.101422] [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: 09/19/2022] [Accepted: 09/21/2022] [Indexed: 11/21/2022]
Abstract
Aortic stenosis (AS) is a progressive disease that carries a poor prognosis. Patients are managed conservatively until satisfying an indication for transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) based on AS severity and the presence of symptoms or adverse impact on the myocardium. Up to 1 in 3 TAVIs are performed for patients with acute symptoms of dyspnoea at rest, angina, and/or syncope - termed acute decompensated aortic stenosis (ADAS) and require urgent aortic valve replacement. These patients have longer hospital length of stay, undergo physical deconditioning, have a higher rate of acute kidney injury and mortality compared to stable patients with less severe symptoms. There is an urgent need to prevent ADAS and to deliver pathways to manage and improve ADAS-related outcomes. We provide here a contemporary review on epidemiological and pathophysiological aspects of ADAS, with a focus on the impact of ADAS from clinical and economic perspectives. We will offer also a global overview of the available evidence for treatment of ADAS and with priorities suggested for addressing current gaps in the literature and unmet clinical needs to improve outcomes for AS patients.
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26
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Ferlini M, Munafò AR, Lanzillo G, Aiello M, Gazzoli F, Mirizzi AM, Magrini G, Pelenghi S, Visconti LO. Early surgical aortic valve replacement in asymptomatic patients with severe aortic stenosis: a systematic review and meta-analysis. J Cardiovasc Med (Hagerstown) 2022; 23:632-634. [PMID: 35905003 DOI: 10.2459/jcm.0000000000001338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Marco Ferlini
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo
| | | | - Giuseppe Lanzillo
- Department of Molecular Medicine, Unit of Cardiology, University of Pavia, Pavia, Italy
| | - Marco Aiello
- Division of Cardiac Surgery, Fondazione IRCCS Policlinico San Matteo
| | - Fabrizio Gazzoli
- Division of Cardiac Surgery, Fondazione IRCCS Policlinico San Matteo
| | | | - Giulia Magrini
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo
| | - Stefano Pelenghi
- Division of Cardiac Surgery, Fondazione IRCCS Policlinico San Matteo
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27
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Iribarren AC, AlBadri A, Wei J, Nelson MD, Li D, Makkar R, Merz CNB. Sex differences in aortic stenosis: Identification of knowledge gaps for sex-specific personalized medicine. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 21:100197. [PMID: 36330169 PMCID: PMC9629620 DOI: 10.1016/j.ahjo.2022.100197] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/18/2022] [Accepted: 08/20/2022] [Indexed: 06/16/2023]
Abstract
Objectives This review summarizes sex-based differences in aortic stenosis (AS) and identifies knowledge gaps that should be addressed by future studies. Background AS is the most common valvular heart disease in developed countries. Sex-specific differences have not been fully appreciated, as a result of widespread under diagnosis of AS in women. Summary Studies including sex-stratified analyses have shown differences in pathophysiology with less calcification and more fibrosis in women's aortic valve. Women have impaired myocardial perfusion reserve and different compensatory response of the left ventricle (LV) to pressure overload, with concentric remodeling and more diffuse fibrosis, in contrast to men with more focal fibrosis and more dilated/eccentrically remodeled LV. There is sex difference in clinical presentation and anatomical characteristics, with women having more paradoxical low-flow/low-gradient AS, under-diagnosis and severity underestimated, with less referral to aortic valve replacement (AVR) compared to men. The response to therapies is also different: women have more adverse events with surgical AVR and greater survival benefit with transcatheter AVR. After AVR, women would have more favorable LV remodeling, but sex-related differences in changes in myocardial reserve flow need future research. Conclusions Investigation into these described sex-related differences in AS offers potential utility for improving prevention and treatment of AS in women and men. To better understand sex-based differences in pathophysiology, clinical presentation, and response to therapies, sex-specific critical knowledge gaps should be addressed in future research for sex-specific personalized medicine.
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Affiliation(s)
- Ana C. Iribarren
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States of America
| | - Ahmed AlBadri
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States of America
| | - Janet Wei
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States of America
- Cedars-Sinai Biomedical Imaging Research Institute, Los Angeles, CA, United States of America
| | - Michael D. Nelson
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States of America
| | - Debiao Li
- Cedars-Sinai Biomedical Imaging Research Institute, Los Angeles, CA, United States of America
| | - Raj Makkar
- Cedars-Sinai Cardiovascular Intervention Center, Smidt Heart Institute, Los Angeles, CA, United States of America
| | - C. Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States of America
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28
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Stassen J, Galloo X, van der Bijl P, Bax JJ. Focus on Diagnosis and Prognosis to Guide Timing of Intervention in Valvular Heart Disease. Curr Cardiol Rep 2022; 24:1407-1416. [PMID: 35925514 PMCID: PMC9556368 DOI: 10.1007/s11886-022-01754-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 12/01/2022]
Abstract
Purpose of Review The present article reviews the role of multimodality imaging to improve risk stratification and timing of intervention in patients with valvular heart disease (VHD), and summarizes the latest developments in transcatheter valve interventions. Recent Findings Growing evidence suggests that intervention at an earlier stage may improve outcomes of patients with significant VHD. Multimodality imaging, including strain imaging and tissue characterization with cardiac magnetic resonance imaging, has the ability to identify early markers of myocardial damage and can help to optimize the timing of intervention. Transcatheter interventions play an increasing role in the treatment of patients who remain at high surgical risk or present at a late stage of their disease. Summary Multimodality imaging identifies markers of cardiac damage at an early stage in the development of VHD. Together with technological innovations in the field of percutaneous valvular devices, these developments have the potential to improve current management and outcomes of patients with significant VHD.
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Affiliation(s)
- Jan Stassen
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.,Department of Cardiology, Jessa Hospital, Stadsomvaart 11, 3500, Hasselt, Belgium
| | - Xavier Galloo
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.,Department of Cardiology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Pieter van der Bijl
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands. .,Turku Heart Center, University of Turku and Turku University Hospital, Kiinamyllynkatu 4-8, 20520, Turku, Finland.
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29
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Ahmad Y, Howard JP, Seligman H, Arnold AD, Madhavan MV, Forrest JK, Geirsson A, Mack MJ, Lansky AJ, Leon MB. Early Surgery for Patients With Asymptomatic Severe Aortic Stenosis: A Meta-Analysis of Randomized Controlled Trials. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100383. [PMID: 39131941 PMCID: PMC11307849 DOI: 10.1016/j.jscai.2022.100383] [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: 03/14/2022] [Revised: 05/03/2022] [Accepted: 05/04/2022] [Indexed: 08/13/2024]
Abstract
Background Guidelines provide class I recommendations for aortic valve intervention for patients with symptomatic severe aortic stenosis (AS) or reduced ejection fraction, but the cornerstone of management for asymptomatic patients has been watchful waiting. This is based on historical nonrandomized data, but randomized controlled trials (RCTs) have now been performed of early surgical aortic valve replacement (SAVR) for asymptomatic severe AS. We performed a meta-analysis of RCTs comparing early SAVR to watchful waiting for asymptomatic severe AS, focusing on individual end points of death and heart failure (HF) hospitalization. Methods We systematically identified all RCTs comparing early SAVR to watchful waiting in patients with asymptomatic severe AS and synthesized the data in a random-effects meta-analysis. The prespecified primary end point was all-cause mortality. Results Two trials randomizing 302 patients were included. Early SAVR lead to a 55% reduction in all-cause mortality (hazard ratio, 0.45; 95% confidence interval, 0.24-0.85; P = .014). There was no heterogeneity (I2 = 0.0%). Early SAVR also lead to a 79% reduction in HF hospitalization (hazard ratio, 0.21; 95% confidence interval, 0.05-0.96; P = .044). Conclusions In patients with severe asymptomatic AS and normal ejection fraction, early SAVR reduces death and HF hospitalization compared to initial conservative management. This challenges current treatment standards and has implications for the clinical care of these patients and for guidelines.
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Affiliation(s)
- Yousif Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - James P. Howard
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Henry Seligman
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Ahran D. Arnold
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Mahesh V. Madhavan
- Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York
- Cardiovascular Research Foundation, New York, New York
| | - John K. Forrest
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Arnar Geirsson
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Michael J. Mack
- Department of Cardiovascular Disease, Baylor Scott and White Health, Plano, Texas
| | - Alexandra J. Lansky
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Martin B. Leon
- Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York
- Cardiovascular Research Foundation, New York, New York
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30
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Narayan P. Management of severe aortic stenosis in asymptomatic patients in the new AVATAR. Indian J Thorac Cardiovasc Surg 2022; 38:454-456. [DOI: 10.1007/s12055-022-01382-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 05/26/2022] [Indexed: 10/18/2022] Open
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31
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Bogdanova M, Zabirnyk A, Malashicheva A, Semenova D, Kvitting JPE, Kaljusto ML, Perez MDM, Kostareva A, Stensløkken KO, Sullivan GJ, Rutkovskiy A, Vaage J. Models and Techniques to Study Aortic Valve Calcification in Vitro, ex Vivo and in Vivo. An Overview. Front Pharmacol 2022; 13:835825. [PMID: 35721220 PMCID: PMC9203042 DOI: 10.3389/fphar.2022.835825] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 04/29/2022] [Indexed: 11/23/2022] Open
Abstract
Aortic valve stenosis secondary to aortic valve calcification is the most common valve disease in the Western world. Calcification is a result of pathological proliferation and osteogenic differentiation of resident valve interstitial cells. To develop non-surgical treatments, the molecular and cellular mechanisms of pathological calcification must be revealed. In the current overview, we present methods for evaluation of calcification in different ex vivo, in vitro and in vivo situations including imaging in patients. The latter include echocardiography, scanning with computed tomography and magnetic resonance imaging. Particular emphasis is on translational studies of calcific aortic valve stenosis with a special focus on cell culture using human primary cell cultures. Such models are widely used and suitable for screening of drugs against calcification. Animal models are presented, but there is no animal model that faithfully mimics human calcific aortic valve disease. A model of experimentally induced calcification in whole porcine aortic valve leaflets ex vivo is also included. Finally, miscellaneous methods and aspects of aortic valve calcification, such as, for instance, biomarkers are presented.
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Affiliation(s)
- Maria Bogdanova
- Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Arsenii Zabirnyk
- Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.,Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Anna Malashicheva
- Institute of Cytology, Russian Academy of Sciences, Saint Petersburg, Russia
| | - Daria Semenova
- Institute of Cytology, Russian Academy of Sciences, Saint Petersburg, Russia
| | | | - Mari-Liis Kaljusto
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway
| | | | - Anna Kostareva
- Almazov National Medical Research Centre, Saint Petersburg, Russia.,Department of Woman and Children Health, Karolinska Institute, Stockholm, Sweden
| | - Kåre-Olav Stensløkken
- Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Gareth J Sullivan
- Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.,Norwegian Center for Stem Cell Research, Oslo University Hospital and University of Oslo, Oslo, Norway.,Institute of Immunology, Oslo University Hospital, Oslo, Norway.,Hybrid Technology Hub - Centre of Excellence, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.,Department of Pediatric Research, Oslo University Hospital, Oslo, Norway
| | - Arkady Rutkovskiy
- Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.,Department of Pulmonary Diseases, Oslo University Hospital, Oslo, Norway
| | - Jarle Vaage
- Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.,Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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32
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Kammoun I, Sghaier A, Bennour E, Laroussi L, Miled M, Neji H, Ben Halima A, Addad F, Marrakchi S, Kachboura S. Current and new imaging techniques in risk stratification of asymptomatic severe aortic stenosis. Acta Cardiol 2022; 77:288-296. [PMID: 34151729 DOI: 10.1080/00015385.2021.1939513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Aortic stenosis (AS) is one of the most common valvular diseases in clinical practice. The prevalence of calcified AS with moderate or severe stenosis exceeds 2% after 75 years. The optimal timing of intervention for asymptomatic severe AS is uncertain and controversial. Identification of high-risk patients is based on echocardiographic parameters (left ventricular dysfunction, AS severity and progression), hemodynamic response to exercise, pulmonary hypertension, and elevated brain natriuretic peptides. However, early surgical aortic valve replacement (AVR), when compared to the watchful waiting approach, was associated with survival advantage. Moreover, new insights into pathophysiology of AS and advances in imaging modalities were helpful in the management of asymptomatic AS. In this report, we detail the potential role of echocardiography to guide timing of surgery and we discussed the use of early risk features based on recent imaging modalities.
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Affiliation(s)
- Ikram Kammoun
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Ahmed Sghaier
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Emna Bennour
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Lobna Laroussi
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Manel Miled
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Henda Neji
- Radiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Afef Ben Halima
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Faouzi Addad
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Sonia Marrakchi
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Salem Kachboura
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
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33
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Tsampasian V, Grafton-Clarke C, Gracia Ramos AE, Asimakopoulos G, Garg P, Prasad S, Ring L, McCann GP, Rudd J, Dweck MR, Vassiliou VS. Management of asymptomatic severe aortic stenosis: a systematic review and meta-analysis. Open Heart 2022; 9:e001982. [PMID: 35581008 PMCID: PMC9109115 DOI: 10.1136/openhrt-2022-001982] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/05/2022] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES The management of severe aortic stenosis mandates consideration of aortic valve intervention for symptomatic patients. However, for asymptomatic patients with severe aortic stenosis, recent randomised trials supported earlier intervention. We conducted a systematic review and meta-analysis to evaluate all the available data comparing the two management strategies. METHODS PubMed, Cochrane and Web of Science databases were systematically searched from inception until 10 January 2022. The search key terms were 'asymptomatic', 'severe aortic stenosis' and 'intervention'. RESULTS Meta-analysis of two published randomised trials, AVATAR and RECOVERY, included 302 patients and showed that early intervention resulted in 55% reduction in all-cause mortality (HR=0.45, 95% CI 0.24 to 0.86; I2 0%) and 79% reduction in risk of hospitalisation for heart failure (HR=0.21, 95% CI 0.05 to 0.96; I2 15%). There was no difference in risk of cardiovascular death between the two groups (HR=0.36, 95% CI 0.03 to 3.78; I2 78%). Additionally, meta-analysis of eight observational studies showed improved mortality in patients treated with early intervention (HR=0.38, 95% CI 0.26 to 0.56; I2 77%). CONCLUSION This meta-analysis provides evidence that, in patients with severe asymptomatic aortic stenosis, early intervention reduces all-cause mortality and improves outcomes compared with conservative management. While this is very encouraging, further randomised controlled studies are needed to draw firm conclusions and identify the optimal timing of intervention. PROSPERO REGISTRATION NUMBER CRD42022301037.
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Affiliation(s)
- Vasiliki Tsampasian
- Cardiology, Norfolk and Norwich University Hospital, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Ciaran Grafton-Clarke
- Cardiology, Norfolk and Norwich University Hospital, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Abraham Edgar Gracia Ramos
- Departamento de Medicina Interna, Centro Medico Nacional "La Raza", IMSS, Ciudad de Mexico, Mexico
- Seccion de Estudios de Posgrado e Investigacion, Escuela Superior de Medicina, Instituto Politecnico Nacional, Mexico City, Mexico
| | - George Asimakopoulos
- Cardiology, Royal Brompton and Harefield NHS Trust, London, UK
- School of Medicine, Imperial College London, London, UK
| | - Pankaj Garg
- Cardiology, Norfolk and Norwich University Hospital, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Sanjay Prasad
- Cardiology, Royal Brompton and Harefield NHS Trust, London, UK
- School of Medicine, Imperial College London, London, UK
| | - Liam Ring
- Cardiology, West Suffolk Hospital NHS Trust, Bury Saint Edmunds, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Leicester NIHR Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - James Rudd
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Vassilios S Vassiliou
- Cardiology, Norfolk and Norwich University Hospital, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
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Outcomes in Patients With Asymptomatic Aortic Stenosis (from the Evolut Low Risk Trial). Am J Cardiol 2022; 168:110-116. [PMID: 35101271 DOI: 10.1016/j.amjcard.2021.12.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/03/2021] [Accepted: 12/07/2021] [Indexed: 01/04/2023]
Abstract
Transcatheter aortic valve implantation (TAVI) has comparable outcomes with surgical aortic valve replacement (SAVR) in symptomatic patients with severe aortic stenosis, including those at low risk for surgery. Less is known about TAVI outcomes in asymptomatic patients. This analysis compares clinical, hemodynamic, and quality of life (QOL) outcomes after TAVI or SAVR for low-risk asymptomatic patients. The randomized Evolut Low Risk trial enrolled asymptomatic patients treated with TAVI (n = 76) and SAVR (n = 62). New York Heart Association functional class I identified patients without symptoms. Clinical outcomes, echocardiographic findings, and QOL in both groups were compared 30 days and 12 months after AVR. Asymptomatic patients had a mean Society of Thoracic Surgeons score of 1.7 ± 0.6, 73% were men, and mean age was 74.2 ± 5.8 years. The composite end point of all-cause mortality or disabling stroke was similar at 12 months in patients with TAVI (1.3%) and SAVR (6.5%; p = 0.11), although patients with SAVR tended to have higher rates of all-cause mortality (4.8%) compared with patients with TAVI (0.0%, p = 0.05). Patients with TAVI had lower mean aortic valve gradients (8.1 ± 3.2 mm Hg) and larger mean effective orifice area (2.3 ± 0.6 mm Hg) than patients with SAVR (10.8 ± 3.8; p <0.001 and 1.9 ± 0.6; p = 0.001, respectively), and showed significant improvement in Kansas City Cardiomyopathy Questionnaire scores from baseline to 30 days (∆12.1 ± 23.6; p <0.001), whereas patients with SAVR did not (∆2.2 ± 20.3; p = 0.398). Patients with TAVI and SAVR had a significant improvement in QOL by 12 months compared with baseline. In conclusion, low risk asymptomatic patients with severe aortic stenosis who underwent TAVI had comparable clinical outcomes to SAVR, with superior valve performance and faster QOL improvement.
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Mohamed MMG, Taha M, Kheiri B, Osman M. Meta-Analysis of Aortic Valve Replacement in Asymptomatic Patients With Severe Aortic Stenosis. Am J Cardiol 2022; 168:174-176. [PMID: 35131098 DOI: 10.1016/j.amjcard.2022.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/02/2022] [Accepted: 01/04/2022] [Indexed: 12/31/2022]
Affiliation(s)
- Mohamed M G Mohamed
- Internal Medicine Department, SSM Health, St. Mary's Hospital-St. Louis, Missouri
| | - Moutaz Taha
- Internal Medicine Department, University of Nevada, Reno, Nevada
| | - Babikir Kheiri
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Mohammed Osman
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
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36
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Surgical aortic valve replacement versus conservative treatment in asymptomatic severe aortic stenosis: An updated systematic review and meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 42:36-44. [DOI: 10.1016/j.carrev.2022.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/17/2022] [Accepted: 03/04/2022] [Indexed: 11/18/2022]
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37
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Xiong T, Han S, Pu L, Zhang TC, Zhan X, Fu T, Dai YH, Li YX. Bioinformatics and Machine Learning Methods to Identify FN1 as a Novel Biomarker of Aortic Valve Calcification. Front Cardiovasc Med 2022; 9:832591. [PMID: 35295271 PMCID: PMC8918776 DOI: 10.3389/fcvm.2022.832591] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/28/2022] [Indexed: 12/14/2022] Open
Abstract
AimThe purpose of this study was to identify potential diagnostic markers for aortic valve calcification (AVC) and to investigate the function of immune cell infiltration in this disease.MethodsThe AVC data sets were obtained from the Gene Expression Omnibus. The identification of differentially expressed genes (DEGs) and the performance of functional correlation analysis were carried out using the R software. To explore hub genes related to AVC, a protein–protein interaction network was created. Diagnostic markers for AVC were then screened and verified using the least absolute shrinkage and selection operator, logistic regression, support vector machine-recursive feature elimination algorithms, and hub genes. The infiltration of immune cells into AVC tissues was evaluated using CIBERSORT, and the correlation between diagnostic markers and infiltrating immune cells was analyzed. Finally, the Connectivity Map database was used to forecast the candidate small molecule drugs that might be used as prospective medications to treat AVC.ResultsA total of 337 DEGs were screened. The DEGs that were discovered were mostly related with atherosclerosis and arteriosclerotic cardiovascular disease, according to the analyses. Gene sets involved in the chemokine signaling pathway and cytokine–cytokine receptor interaction were differently active in AVC compared with control. As the diagnostic marker for AVC, fibronectin 1 (FN1) (area the curve = 0.958) was discovered. Immune cell infiltration analysis revealed that the AVC process may be mediated by naïve B cells, memory B cells, plasma cells, activated natural killer cells, monocytes, and macrophages M0. Additionally, FN1 expression was associated with memory B cells, M0 macrophages, activated mast cells, resting mast cells, monocytes, and activated natural killer cells. AVC may be reversed with the use of yohimbic acid, the most promising small molecule discovered so far.ConclusionFN1 can be used as a diagnostic marker for AVC. It has been shown that immune cell infiltration is important in the onset and progression of AVC, which may benefit in the improvement of AVC diagnosis and treatment.
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Affiliation(s)
- Tao Xiong
- Cardiovascular Surgery, Yan'an Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
| | - Shen Han
- Cardiovascular Surgery, Yan'an Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
- Key Laboratory of Cardiovascular Disease of Yunnan Province, Yan'an Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
| | - Lei Pu
- Cardiovascular Surgery, Yan'an Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
- Key Laboratory of Cardiovascular Disease of Yunnan Province, Yan'an Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
| | - Tian-Chen Zhang
- Cardiovascular Surgery, Yan'an Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
| | - Xu Zhan
- Department of Thoracic and Cardiovascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Tao Fu
- Cardiovascular Surgery, Yan'an Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
| | - Ying-Hai Dai
- Cardiovascular Surgery, Yan'an Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
| | - Ya-Xiong Li
- Cardiovascular Surgery, Yan'an Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
- Key Laboratory of Cardiovascular Disease of Yunnan Province, Yan'an Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
- *Correspondence: Ya-Xiong Li ;
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Mantha Y, Futami S, Moriyama S, Hieda M. Valvulo-Arterial Impedance and Dimensionless Index for Risk Stratifying Patients With Severe Aortic Stenosis. Front Cardiovasc Med 2021; 8:742297. [PMID: 34926605 PMCID: PMC8674501 DOI: 10.3389/fcvm.2021.742297] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 10/25/2021] [Indexed: 11/22/2022] Open
Abstract
The hemodynamic effects of aortic stenosis (AS) consist of increased left ventricular (LV) afterload, reduced myocardial compliance, and increased myocardial workload. The LV in AS patients faces a double load: valvular and arterial loads. As such, the presence of symptoms and occurrence of adverse events in AS should better correlate with calculating the global burden faced by the LV in addition to the transvalvular gradient and aortic valve area (AVA). The valvulo-arterial impedance (Zva) is a useful parameter providing an estimate of the global LV hemodynamic load that results from the summation of the valvular and vascular loads. In addition to calculating the global LV afterload, it is paramount to estimate the stenosis severity accurately. In clinical practice, the management of low-flow low-gradient (LF-LG) severe AS with preserved LV ejection fraction requires careful confirmation of stenosis severity. In addition to the Zva, the dimensionless index (DI) is a very useful parameter to express the size of the effective valvular area as a proportion of the cross-section area of the left ventricular outlet tract velocity-time integral (LVOT-VTI) to that of the aortic valve jet (dimensionless velocity ratio). The DI is calculated by a ratio of the sub-valvular velocity obtained by pulsed-wave Doppler (LVOT-VTI) divided by the maximum velocity obtained by continuous-wave Doppler across the aortic valve (AV-VTI). In contrast to AVA measurement, the DI does not require the calculation of LVOT cross-sectional area, a major cause of erroneous assessment and underestimation of AVA. Hence, among patients with LG severe AS and preserved LV ejection fraction, calculation of DI in routine echocardiographic practice may be useful to identify a subgroup of patients at higher risk of mortality who may derive benefit from aortic valve replacement. This article aims to elucidate the Zva and DI in different clinical situations, correlate with the standard indexes of AS severity, LV geometry, and function, and thus prove to improve risk stratification and clinical decision making in patients with severe AS.
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Affiliation(s)
- Yogamaya Mantha
- Division of Cardiovascular Medicine, University of Texas Health Sciences, San Antonio, TX, United States
| | - Shutaro Futami
- Department of Medicine and Biosystemic Science, Hematology, Oncology and Cardiovascular Medicine, School of Medicine, Kyushu University, Fukuoka, Japan
| | - Shohei Moriyama
- Department of Medicine and Biosystemic Science, Hematology, Oncology and Cardiovascular Medicine, School of Medicine, Kyushu University, Fukuoka, Japan
| | - Michinari Hieda
- Department of Medicine and Biosystemic Science, Hematology, Oncology and Cardiovascular Medicine, School of Medicine, Kyushu University, Fukuoka, Japan
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39
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Sevilla T, Revilla-Orodea A, San Román JA. Timing of Intervention in Asymptomatic Patients with Aortic Stenosis. Eur Cardiol 2021; 16:e32. [PMID: 34603512 PMCID: PMC8477179 DOI: 10.15420/ecr.2021.11] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/25/2021] [Indexed: 11/23/2022] Open
Abstract
Aortic stenosis is a very common disease. Current guidelines recommend intervention mainly in symptomatic patients; aortic valve replacement can be considered in asymptomatic patients under specific conditions, but the evidence supporting these indications is poor. Continuous advances in both surgical and percutaneous techniques have substantially decreased rates of perioperative complications and mortality; with this in mind, many authors suggest that earlier intervention in patients with severe aortic stenosis, when they are still asymptomatic, may be indicated. This paper summarises what is known about the natural history of severe aortic stenosis and the scientific evidence available about the optimal timing for aortic valve replacement.
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Affiliation(s)
- Teresa Sevilla
- Department of Cardiology, Hospital Clínico Universitario de Valladolid Valladolid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares Madrid, Spain
| | - Ana Revilla-Orodea
- Department of Cardiology, Hospital Clínico Universitario de Valladolid Valladolid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares Madrid, Spain
| | - J Alberto San Román
- Department of Cardiology, Hospital Clínico Universitario de Valladolid Valladolid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares Madrid, Spain
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40
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Desai MY, Alashi A, Popovic ZB, Wierup P, Griffin BP, Thamilarasan M, Johnston D, Svensson LG, Lever HM, Smedira NG. Outcomes in Patients With Obstructive Hypertrophic Cardiomyopathy and Concomitant Aortic Stenosis Undergoing Surgical Myectomy and Aortic Valve Replacement. J Am Heart Assoc 2021; 10:e018435. [PMID: 34533040 PMCID: PMC8649531 DOI: 10.1161/jaha.120.018435] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Hypertrophic cardiomyopathy (HCM) and aortic stenosis can cause obstruction to the flow of blood out of the left ventricular outflow tract into the aorta, with obstructive HCM resulting in dynamic left ventricular outflow tract obstruction and moderate or severe aortic stenosis causing fixed obstruction caused by calcific degeneration. We sought to report the characteristics and longer-term outcomes of patients with severe obstructive HCM who also had concomitant moderate or severe aortic stenosis requiring surgical myectomy and aortic valve replacement. Methods and Results We studied 191 consecutive patients (age 67±6 years, 52% men) who underwent myectomy and aortic valve (AV) replacement (90% bioprosthesis) at our center between June 2002 and June 2018. Clinical and echo data including left ventricular outflow tract gradient and indexed AV area were recorded. The primary outcome was death. Prevalence of hypertension (63%) and hyperlipidemia (75%) were high, with a Society of Thoracic Surgeons score of 5±4, and 70% of participants had no HCM-related sudden death risk factors. Basal septal thickness and indexed AV area were 1.9±0.4 cm and 0.72±0.2 cm2/m2, respectively, while 100% of patients had dynamic left ventricular outflow tract gradient >50 mm Hg. At 6.5±4 years, 52 (27%) patients died (1.5% in-hospital deaths). One-, 2-, and 5-year survival in the current study sample was 94%, 91%, and 83%, respectively, similar to an age-sex-matched general US population. On multivariate Cox survival analysis, age (hazard ratio [HR], 1.65; 95% CI, 1.24-2.18), chronic kidney disease (HR, 1.58; 95% CI, 1.21-2.32), and right ventricular systolic pressure on preoperative echocardiography (HR, 1.28; 95% CI, 1.05-1.57) were associated with longer-term mortality, but traditional HCM risk factors did not. Conclusions In symptomatic patients with severely obstructive HCM and moderate or severe aortic stenosis undergoing a combined surgical myectomy and AV replacement at our center, the observed postoperative mortality was significantly lower than the expected mortality, and the longer-term survival was similar to a normal age-sex-matched US population.
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Affiliation(s)
- Milind Y Desai
- Hypertrophic Cardiomyopathy and Valve Center Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Alaa Alashi
- Hypertrophic Cardiomyopathy and Valve Center Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Zoran B Popovic
- Hypertrophic Cardiomyopathy and Valve Center Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Per Wierup
- Hypertrophic Cardiomyopathy and Valve Center Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Brian P Griffin
- Hypertrophic Cardiomyopathy and Valve Center Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Maran Thamilarasan
- Hypertrophic Cardiomyopathy and Valve Center Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Douglas Johnston
- Hypertrophic Cardiomyopathy and Valve Center Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Lars G Svensson
- Hypertrophic Cardiomyopathy and Valve Center Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Harry M Lever
- Hypertrophic Cardiomyopathy and Valve Center Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Nicholas G Smedira
- Hypertrophic Cardiomyopathy and Valve Center Heart and Vascular Institute Cleveland Clinic Cleveland OH
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Shah BN, Kalra A, Tajik AJ. What is 'very severe' aortic stenosis? A proposal for a new category of severity in the classification of aortic stenosis. Eur Heart J Cardiovasc Imaging 2021; 22:e84-e86. [PMID: 33846717 DOI: 10.1093/ehjci/jeab054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 03/11/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Benoy Nalin Shah
- Department of Cardiology, Wessex Cardiac Centre, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
| | - Ankur Kalra
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.,Section of Cardiovascular Research, Heart, Vascular, and Thoracic Department, Cleveland Clinic Akron General, Akron, OH, USA
| | - Abdul Jamil Tajik
- Department of Cardiology, Aurora Sinai Medical Center, Milwaukee, WI, USA
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42
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Lee SA, Kang DH. Timing of Intervention in Asymptomatic Aortic Stenosis. Circ J 2021; 86:376-382. [PMID: 34176862 DOI: 10.1253/circj.cj-21-0200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The decision to perform an intervention for asymptomatic severe aortic stenosis (AS) requires careful weighing of the risks of early intervention against those of watchful observation, and the optimal timing of intervention remains controversial. With improvements in surgical and postoperative care, long-term survival after surgical aortic valve (AV) replacement (AVR) is excellent in low-risk patients, and the emergence of transcatheter AVR may change the thresholds for early preemptive intervention, although a durability issue has to be resolved. A watchful observation strategy also has a risk of sudden death, irreversible myocardial damage, and increase in operative risk while waiting for symptoms to develop. We have been waiting for a prospective randomized trial to solve the intense debate between early AVR and watchful observation, and the RECOVERY (Randomized Comparison of Early Surgery versus Conventional Treatment in Very Severe Aortic Stenosis) trial provides the evidence to support early AVR for asymptomatic severe AS. Risk assessment with severity of AS and staging classification may help to facilitate the identification of patients who may benefit from early intervention. Based on the results of the RECOVERY trial, early surgical AVR is reasonable for asymptomatic patients with very severe AS (aortic jet velocity ≥4.5 m/s) and low surgical risk. Further evidence is required to extend the indications of surgical AVR and to consider transcatheter AVR in asymptomatic patients with severe AS.
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Affiliation(s)
- Seung-Ah Lee
- Division of Cardiology, Asan Medical Center, College of Medicine, University of Ulsan
| | - Duk-Hyun Kang
- Division of Cardiology, Asan Medical Center, College of Medicine, University of Ulsan
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Mourino-Alvarez L, Corbacho-Alonso N, Sastre-Oliva T, Corros-Vicente C, Solis J, Tejerina T, Padial LR, Barderas MG. Diabetes Mellitus and Its Implications in Aortic Stenosis Patients. Int J Mol Sci 2021; 22:ijms22126212. [PMID: 34207517 PMCID: PMC8227301 DOI: 10.3390/ijms22126212] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/04/2021] [Accepted: 06/07/2021] [Indexed: 12/18/2022] Open
Abstract
Aortic stenosis (AS) and diabetes mellitus (DM) are both progressive diseases that if left untreated, result in significant morbidity and mortality. Several studies revealed that the prevalence of DM is substantially higher in patients with AS and, thus, the progression from mild to severe AS is greater in those patients with DM. DM and common comorbidities associated with both diseases, DM and AS, increase patient management complexity and make aortic valve replacement the only effective treatment. For that reason, a better understanding of the pathogenesis underlying both these diseases and the relationships between them is necessary to design more appropriate preventive and therapeutic approaches. In this review, we provided an overview of the main aspects of the relationship between AS and DM, including common comorbidities and risk factors. We also discuss the established treatments/therapies in patients with AS and DM.
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Affiliation(s)
- Laura Mourino-Alvarez
- Department of Vascular Physiopathology, Hospital Nacional de Paraplejicos (HNP), SESCAM, 45071 Toledo, Spain; (L.M.-A.); (N.C.-A.); (T.S.-O.); (C.C.-V.)
| | - Nerea Corbacho-Alonso
- Department of Vascular Physiopathology, Hospital Nacional de Paraplejicos (HNP), SESCAM, 45071 Toledo, Spain; (L.M.-A.); (N.C.-A.); (T.S.-O.); (C.C.-V.)
| | - Tamara Sastre-Oliva
- Department of Vascular Physiopathology, Hospital Nacional de Paraplejicos (HNP), SESCAM, 45071 Toledo, Spain; (L.M.-A.); (N.C.-A.); (T.S.-O.); (C.C.-V.)
| | - Cecilia Corros-Vicente
- Department of Vascular Physiopathology, Hospital Nacional de Paraplejicos (HNP), SESCAM, 45071 Toledo, Spain; (L.M.-A.); (N.C.-A.); (T.S.-O.); (C.C.-V.)
| | - Jorge Solis
- Department of Cardiology, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain
- Atria Clinic, 28009 Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Correspondence: (J.S.); or (M.G.B.); Fax: +34-925247745 (M.G.B.)
| | - Teresa Tejerina
- Department of Pharmacology, School of Medicine, Universidad Complutense, 28040 Madrid, Spain;
| | - Luis R. Padial
- Department of Cardiology, Hospital Virgen de la Salud, SESCAM, 45004 Toledo, Spain;
| | - Maria G. Barderas
- Department of Vascular Physiopathology, Hospital Nacional de Paraplejicos (HNP), SESCAM, 45071 Toledo, Spain; (L.M.-A.); (N.C.-A.); (T.S.-O.); (C.C.-V.)
- Correspondence: (J.S.); or (M.G.B.); Fax: +34-925247745 (M.G.B.)
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Pyo WK, Kim HJ, Kim JB, Jung SH, Choo SJ, Chung CH, Lee JW. Does Surgical Ablation of Atrial Fibrillation Benefit Patients Undergoing Bioprosthetic Valve Replacement? Semin Thorac Cardiovasc Surg 2021; 34:906-915. [PMID: 34091016 DOI: 10.1053/j.semtcvs.2021.05.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 05/21/2021] [Indexed: 11/11/2022]
Abstract
The benefit of avoiding lifelong anticoagulation therapy in patients with bioprosthetic heart valve implantation may potentially be offset by atrial fibrillation (AF); however, clinical impact of surgical AF ablation in such patients remains controversial. We enrolled 426 patients (aged 72.0 ± 7.8 years) with AF who underwent left-side valve replacement with bioprostheses between 2001 and 2018. Of these, 297 underwent concomitant surgical ablation (ablation group) and 129 underwent valve replacement alone (non-ablation group). Clinical outcomes were compared, and mortality was considered as a competing risk factor against valve-related complications. Inverse-probability weighting (IPTW) was adopted to reduce selection bias. The ablation group had lower baseline risk profiles than the non-ablation group. In crude analysis, early mortality rates were 3.4% and 7.0% in the ablation and non-ablation groups, respectively (P = 0.104). During follow-up (1521.9 patient-years), the ablation group showed lower AF-recurrence (P < 0.001) and anticoagulant medication rate (P = 0.021), and lower overall mortality risk (subdistribution hazard ratio [SHR], 0.63; 95% confidence interval [CI], 0.42-0.94), but higher risk of permanent pacemaker implantation (SHR, 4.67; 95% CI, 1.36-16.05). No significant difference in the risk of stroke (SHR, 1.27; 95% CI, 0.55-2.95) was observed between the groups. After baseline IPTW-adjustment, findings of the clinical outcomes were analogous to those from crude analyses. In patients undergoing bioprosthetic valve replacement, the addition of surgical ablation was associated with improved rhythm outcomes and survival but at the expense of a higher risk of pacemaker implantation. The underlying mechanism of improved survival by AF ablation needs further investigation.
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Affiliation(s)
- Won Kyung Pyo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ho Jin Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Suk Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Cheol Hyun Chung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Won Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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45
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Percutaneous versus Surgical Intervention for Severe Aortic Valve Stenosis: A Systematic Review. BIOMED RESEARCH INTERNATIONAL 2021; 2021:3973924. [PMID: 34136565 PMCID: PMC8175165 DOI: 10.1155/2021/3973924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/04/2021] [Accepted: 05/14/2021] [Indexed: 11/18/2022]
Abstract
Aortic stenosis is a disease that is increasing in prevalence and manifests as decreased cardiac output, which if left untreated can result in heart failure and ultimately death. It is primarily a disease of the elderly who often have multiple comorbidities. The advent of transcatheter aortic valve therapies has changed the way we treat these conditions. However, long-term results of these therapies remain uncertain. Recently, there has been an increasing number of studies examining the role of both surgical aortic valve replacement and transcatheter aortic valve replacement. We therefore performed a systematic review using Ovid MEDLINE, Ovid Embase, and the Cochrane Library. Two investigators searched papers published between January 1, 2007, and to date using the following terms: "aortic valve stenosis," "aortic valve operation," and "transcatheter aortic valve therapy." Both strategies in aortic stenosis treatment highlighted specific indications alongside the pitfalls such as structural valve degeneration and valve thrombosis which have a bearing on clinical outcomes. We propose some recommendations to help clinicians in the decision-making process as technological improvements make both surgical and transcatheter therapies viable options for patients with aortic stenosis. Finally, we assess the role of finite element analysis in patient selection for aortic valve replacement. THVT and AVR-S are both useful tools in the armamentarium against aortic stenosis. The decision between the two treatment strategies should be best guided by a strong robust evidence base, ideally with a long-term follow-up. This is best performed by the heart team with the patient as the center of the discussion.
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46
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Einarsen E, Hjertaas JJ, Gu H, Matre K, Chowienczyk PJ, Gerdts E, Chambers JB, Saeed S. Impact of arterio-ventricular interaction on first-phase ejection fraction in aortic stenosis. Eur Heart J Cardiovasc Imaging 2021; 22:650-657. [PMID: 32793965 PMCID: PMC8110316 DOI: 10.1093/ehjci/jeaa154] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 01/30/2020] [Accepted: 05/14/2020] [Indexed: 11/13/2022] Open
Abstract
AIMS First-phase ejection fraction (EF1), the EF at the time to peak aortic jet velocity, has been proposed as a novel marker of peak systolic function in aortic stenosis (AS). This study aimed to explore the association of myocardial contractility and arterial load with EF1 in AS patients. METHODS AND RESULTS Data from a prospective, cross-sectional study of 114 patients with mild, moderate, and severe AS with preserved left ventricular EF (>50%) were analysed. EF1 was measured as the volume change from end-diastole to the time that corresponded to peak aortic jet velocity. Myocardial contractility was assessed by strain rate measured by speckle tracking echocardiography. Arterial stiffness was assessed by central pulse pressure/stroke volume index ratio (PP/SVi). The total study population included 48% women, median age was 73 years, and mean peak aortic jet velocity was 3.47 m/s. In univariable linear regression analyses, lower EF1 was associated with higher age, higher peak aortic jet velocity, lower global EF, lower global longitudinal strain, lower strain rate, and higher PP/SVi. There was no significant association between EF1 and heart rate or sex. In multivariable linear regression analysis, EF1 was associated with lower strain rate and higher PP/SVi, independent of AS severity. Replacing PP/SVi by valvular impedance did not change the results. CONCLUSION In patients with AS, reduced myocardial contractility and increased arterial load were associated with lower EF1 independent of the severity of valve stenosis.
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Affiliation(s)
- Eigir Einarsen
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Corresponding author. Tel: +47 98096917. E-mail:
| | | | - Haotian Gu
- British Heart Foundation Centre, King’s College London, London, UK
| | - Knut Matre
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | | | - Eva Gerdts
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - John B Chambers
- Cardiothoracic Centre, Guy’s and St Thomas’ Hospital, London, UK
| | - Sahrai Saeed
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
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47
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2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2021; 162:e183-e353. [PMID: 33972115 DOI: 10.1016/j.jtcvs.2021.04.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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48
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Ring L, Shah BN, Bhattacharyya S, Harkness A, Belham M, Oxborough D, Pearce K, Rana BS, Augustine DX, Robinson S, Tribouilloy C. Echocardiographic assessment of aortic stenosis: a practical guideline from the British Society of Echocardiography. Echo Res Pract 2021; 8:G19-G59. [PMID: 33709955 PMCID: PMC8115410 DOI: 10.1530/erp-20-0035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 03/11/2021] [Indexed: 12/15/2022] Open
Abstract
The guideline provides a practical step-by-step guide in order to facilitate high-quality echocardiographic studies of patients with aortic stenosis. In addition, it addresses commonly encountered yet challenging clinical scenarios and covers the use of advanced echocardiographic techniques, including TOE and Dobutamine stress echocardiography in the assessment of aortic stenosis.
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Affiliation(s)
- Liam Ring
- West Suffolk Hospital NHS Foundation Trust, Bury St Edmunds, UK
| | - Benoy N Shah
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Allan Harkness
- East Suffolk and North Essex NHS Foundation Trust, Colchester, UK
| | - Mark Belham
- Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - David Oxborough
- Liverpool John Moores University, Research Institute for Sports and Exercise Physiology, Liverpool, UK
| | | | - Bushra S Rana
- Imperial College Healthcare NHS Trust, London, UK
- National Heart and Lung Institute, Imperial College, London
| | - Daniel X Augustine
- Royal United Hospital NHS Foundation Trust, Bath, UK
- Department for Health, University of Bath, Bath, UK
| | - Shaun Robinson
- North West Anglia NHS Foundation Trust, Peterborough, UK
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49
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Minamino-Muta E, Kato T, Morimoto T, Taniguchi T, Ando K, Kanamori N, Murata K, Kitai T, Kawase Y, Miyake M, Izumi C, Mitsuoka H, Kato M, Hirano Y, Matsuda S, Nagao K, Murakami T, Takeuchi Y, Yamane K, Toyofuku M, Ishii M, Inoko M, Ikeda T, Ishii K, Hotta K, Jinnai T, Kato Y, Inuzuka Y, Maeda C, Morikami Y, Saito N, Minatoya K, Kimura T. A risk prediction model in asymptomatic patients with severe aortic stenosis: CURRENT-AS risk score. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 6:166-174. [PMID: 31386103 DOI: 10.1093/ehjqcco/qcz044] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/26/2019] [Accepted: 08/05/2019] [Indexed: 02/06/2023]
Abstract
AIMS Early aortic valve replacement (AVR) might be beneficial in selected high-risk asymptomatic patients with severe aortic stenosis (AS), considering their poor prognosis when managed conservatively. This study aimed to develop and validate a clinical scoring system to predict AS-related events within 1 year after diagnosis in asymptomatic severe AS patients. METHODS AND RESULTS We analysed 1274 asymptomatic severe AS patients derived from a retrospective multicentre registry enrolling consecutive patients with severe AS in Japan (CURRENT AS registry), who were managed conservatively and completed 1-year follow-up without AVR. From a randomly assigned derivation set (N = 849), we developed CURRENT AS risk score for the AS-related event (a composite of AS-related death and heart failure hospitalization) within 1 year using a multivariable logistic regression model. The risk score comprised independent risk predictors including left ventricular ejection fraction <60%, haemoglobin ≤11.0 g/dL, chronic lung disease (2 points), diabetes mellitus, haemodialysis, and any concomitant valve disease (1 point). The predictive accuracy of the model was good with the area under the curve of 0.79 and 0.77 in the derivation and validation sets (N = 425). In the validation set, the 1-year incidence of AS-related events was much higher in patients with score ≥2 than in patients with score ≤1 (Score 0: 2.2%, Score 1: 1.9%, Score 2: 13.4%, Score 3: 14.3%, and Score ≥4: 22.7%, P < 0.001). CONCLUSION The CURRENT-AS risk score integrating clinical and echocardiographic factors well-predicted the risk of AS-related events at 1 year in asymptomatic patients with severe AS and was validated internally.
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Affiliation(s)
- Eri Minamino-Muta
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Takao Kato
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo 663-8501, Japan
| | - Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, 3-2-1 Asano, Kokurakita-ku, Kokura, Fukuoka 802-8555, Japan
| | - Norio Kanamori
- Division of Cardiology, Shimada Municipal Hospital, 1200-5 Noda, Shimada, Shizuoka 427-8502, Japan
| | - Koichiro Murata
- Department of Cardiology, Shizuoka City Shizuoka Hospital, 10-93 Otemachi, Aoi-ku, Shizuoka 420-8630, Japan
| | - Takeshi Kitai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojimaminamimachi, Chuo-ku, Kobe-City, Hyogo 650-0047, Japan
| | - Yuichi Kawase
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama 710-8602, Japan
| | - Makoto Miyake
- Department of Cardiology, Tenri Hospital, Tenri, Japan
| | - Chisato Izumi
- Division of Heart Failure, National Cerebral and Cardiovascular Center, 200 Mishima-cho, Tenri, Nara 632-8555, Japan
| | - Hirokazu Mitsuoka
- Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine, 1248-1 Otoda-cho, Ikoma, Nara 630-0293, Japan
| | - Masashi Kato
- Department of Cardiology, Mitsubishi Kyoto Hospital, 1 Katsuragosho-cho, Nishigyo-ku, Kyoto 615-8087, Japan
| | - Yutaka Hirano
- Department of Cardiology, Kinki University Hospital, 377-2 Ohno-higashi, Sayama, Osaka 589-8511, Japan
| | - Shintaro Matsuda
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Kazuya Nagao
- Department of Cardiovascular Center, Osaka Red Cross Hospital, 5-30 Hudegasaki, Tennoji-Ku, Osaka 543-8555, Japan
| | - Tomoyuki Murakami
- Department of Cardiology, Koto Memorial Hospital, 2-1 Hiramatsu-cho, Higashioumi, Shiga 527-0134, Japan
| | - Yasuyo Takeuchi
- Department of Cardiology, Shizuoka General Hospital, 4-27-1 Kitaando-cho, Aoi-ku, Shizuoka 420-8257, Japan
| | - Keiichiro Yamane
- Department of Cardiology, Nishikobe Medical Center, 5-7-1 Kojida-, Nishi-ku, Kobe 651-2273, Japan
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, 4-20 Komatsubara-dori, Wakayama 640-8558, Japan
| | - Mitsuru Ishii
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1 Fukakusamukaihata-cho, Fushimi-ku, Kyoto 612-8555, Japan
| | - Moriaki Inoko
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, 2-4-20 Ohgimachi, Kita-ku, Osaka 530-8480, Japan
| | - Tomoyuki Ikeda
- Department of Cardiology, Hikone Municipal Hospital, 1882 Yasaka-cho, Hikone, Shiga 522-8539, Japan
| | - Katsuhisa Ishii
- Department of Cardiology, Kansai Electric Power Hospital, 2-1-7 Fukushima, Fukushima-ku, Osaka 553-0003, Japan
| | - Kozo Hotta
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77 Higashi-naniwa-cho, Amagasaki, Hyogo 660-8550, Japan
| | - Toshikazu Jinnai
- Department of Cardiology, Japanese Red Cross Otsu Hospital, 1-1-35 Nagara, Otsu, Shiga 520-0046, Japan
| | - Yoshihiro Kato
- Department of Cardiology, Saiseikai Noe Hospital, 1-3-25 Furuichi, Joto-ku, Osaka 536-0001, Japan
| | - Yasutaka Inuzuka
- Department of Cardiology, Shiga Medical Center for Adults, 5-4-3 Moriyama, Moriyama, Shiga 524-8524, Japan
| | - Chiyo Maeda
- Department of Cardiology, Hamamatsu Rosai Hospital, 25 Shogen-cho, Higashi-ku, Hamamatsu, Shizuoka 430-8525, Japan
| | - Yuko Morikami
- Department of Cardiology, Hirakata Kohsai Hospital, 1-2-2-1 Hujisakahigashi-cho, Hirakata, Osaka 573-0153, Japan
| | - Naritatsu Saito
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
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50
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Perry AS, Li S. Optimal Threshold of Left Ventricular Ejection Fraction for Aortic Valve Replacement in Asymptomatic Severe Aortic Stenosis: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2021; 10:e020252. [PMID: 33787311 PMCID: PMC8174345 DOI: 10.1161/jaha.120.020252] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background The optimal threshold of left ventricular ejection fraction (LVEF) that should prompt aortic valve replacement (AVR) in asymptomatic patients with high‐gradient severe aortic stenosis (AS) is controversial. The aim of this study was to assess the relationship between LVEF and mortality benefit in comparing early AVR versus watchful waiting in asymptomatic patients with severe AS. Methods and Results MEDLINE, Embase, Web of Science, and Google Scholar were searched for observational studies and randomized controlled trials on adults with asymptomatic severe AS. Severe AS was defined by a peak aortic velocity ≥4 m/s and/or mean aortic valve gradient ≥40 mm Hg and/or calculated aortic valve area <1.0 cm2 or an indexed valve area <0.6 cm2. Studies comparing AVR with conservative management were included and meta‐analysis on all‐cause mortality was performed. Ten eligible studies were identified with a total of 3332 patients. In 5 observational studies comparing early AVR versus watchful waiting, our meta‐analysis showed early AVR was associated with lower mortality with a hazard ratio (HR) of 0.41 (CI, 0.23–0.71; P<0.01). In 4 observational studies comparing AVR versus no AVR, our meta‐analysis showed AVR was associated with lower mortality with a HR of 0.31 (CI, 0.17–0.58; P<0.001). In a meta‐regression analysis pooling all 10 studies, there was no statistically significant correlation between study mean LVEF and the size of mortality benefit of AVR (P=0.83). Conclusions Among asymptomatic patients with high‐gradient severe AS, AVR was associated with a mortality benefit across the spectrum of LVEF. Our study calls into question the need of an LVEF threshold for recommending AVR in this patient population.
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Affiliation(s)
- Andrew S Perry
- Division of Cardiology University of Washington School of Medicine Seattle WA
| | - Song Li
- Division of Cardiology University of Washington School of Medicine Seattle WA
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