Changes in Left Ventricular Global Longitudinal Strain in Patients With Heart Failure and Secondary Mitral Regurgitation: The COAPT Trial

Background Left ventricular (LV) global longitudinal strain (GLS) provides incremental prognostic information over LV ejection fraction in patients with heart failure (HF) and secondary mitral regurgitation. We examined the prognostic impact of LV GLS improvement in this population. Methods and Results The COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) trial randomized symptomatic patients with HF with severe (3+/4+) mitral regurgitation to transcatheter edge-to-edge repair with the MitraClip device plus maximally tolerated guideline-directed medical therapy (GDMT) versus GDMT alone. LV GLS was measured at baseline and 6-month follow-up. The relationship between the improvement in LV GLS from baseline to 6 months and the composite of all-cause death or HF hospitalization between 6- and 24-month follow-up were assessed. Among 383 patients, 174 (45.4%) had improved LV GLS at 6-month follow-up (83/195 [42.6%] with transcatheter edge-to-edge repair+GDMT and 91/188 [48.4%] with GDMT alone; P=0.25). Improvement in LV GLS was strongly associated with reduced death or HF hospitalization between 6 and 24 months (P<0.009), with similar risk reduction in both treatment arms (Pinteraction=0.40). By multivariable analysis, LV GLS improvement at 6 months was independently associated with a lower risk of death or HF hospitalization (hazard ratio [HR], 0.55 [95% CI, 0.36-0.83]; P=0.009), death (HR, 0.48 [95% CI, 0.29-0.81]; P=0.006), and HF hospitalization (HR, 0.50 [95% CI, 0.31-0.81]; P=0.005) between 6 and 24 months. Conclusions Among patients with HF and severe mitral regurgitation in the COAPT trial, improvement in LV GLS at 6-month follow-up was associated with improved outcomes after both transcatheter edge-to-edge repair and GDMT alone between 6 and 24 months. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01626079.

Incremental value of left ventricular global longitudinal strain in moderate aortic stenosis and reduced left ventricular ejection fraction

BACKGROUND

Moderate aortic stenosis (AS) often coexists with left ventricular (LV) systolic dysfunction and may affect survival through afterload mismatch. Because outcomes are ultimately driven by the condition of the LV, accurate assessment of LV performance is crucial to improve risk stratification. This study investigated the prognostic value of LV global longitudinal strain (GLS) in patients with moderate AS and reduced LV systolic dysfunction.

METHODS

Patients with moderate AS (aortic valve area 1.0-1.5 cm²) and reduced LV ejection fraction (EF) (<50%) were identified. LVGLS was evaluated with speckle-tracking echocardiography. Patients were divided into 2 groups according to an LVGLS value of 11%, based on spline curve analysis. The primary endpoint was all-cause mortality.

RESULTS

A total of 166 patients (mean age 73 ± 11 years, 71% male) were included. The cumulative 1- and 5-year mortality rates were higher in patients with LVGLS <11% (25% and 60%) versus LVGLS ≥11% (10% and 27%) (p < 0.001). On multivariable analysis, LVGLS as a continuous variable (HR 0.753; 95% CI 0.673-0.843; p < 0.001) and as a categorical variable (<11%) (HR 3.028; 95% CI 1.623-5.648; p < 0.001) were independently associated with outcomes, whereas LVEF was not. LVGLS provided additional prognostic information in patients with/without coronary artery disease and with mildly versus severely reduced LVEF. In addition, LVGLS had incremental prognostic value over established risk factors, including LVEF.

CONCLUSION

The combination of moderate AS and reduced LV systolic dysfunction is associated with a high mortality risk. LVGLS, but not LVEF, is independently associated with mortality and provides incremental prognostic value over established risk factors in patients with moderate AS and reduced LVEF.

Managing Patients With Moderate Aortic Stenosis

Current guidelines recommend that clinical surveillance for patients with moderate aortic stenosis (AS) and aortic valve replacement (AVR) may be considered if there is an indication for coronary revascularization. Recent observational studies, however, have shown that moderate AS is associated with an increased risk of cardiovascular events and mortality. Whether the increased risk of adverse events is caused by associated comorbidities, or to the underlying moderate AS itself, is incompletely understood. Similarly, which patients with moderate AS need close follow-up or could potentially benefit from early AVR is also unknown. In this review, the authors provide a comprehensive overview of the current literature on moderate AS. They first provide an algorithm that helps to diagnose moderate AS correctly, especially when discordant grading is observed. Although the traditional focus of AS assessment has been on the valve, it is increasingly acknowledged that AS is not only a disease of the aortic valve but also of the ventricle. The authors therefore discuss how multimodality imaging can help to evaluate the left ventricular remodeling response and improve risk stratification in patients with moderate AS. Finally, they summarize current evidence on the management of moderate AS and highlight ongoing trials on AVR in moderate AS.

Impact of Left Ventricular Ejection Fraction on Clinical Outcomes in Bicuspid Aortic Valve Disease

BACKGROUND

The prognostic impact of left ventricular ejection fraction (LVEF) in patients with bicuspid aortic valve (BAV) disease has not been previously studied.

OBJECTIVES

The purpose of this study was to determine the prognostic impact of LVEF in BAV patients according to the type of aortic valve dysfunction.

METHODS

We retrospectively analyzed the data collected in 2,672 patients included in an international registry of patients with BAV. Patients were classified according to the type of aortic valve dysfunction: isolated aortic stenosis (AS) (n = 749), isolated aortic regurgitation (AR) (n = 554), mixed aortic valve disease (MAVD) (n = 190), or no significant aortic valve dysfunction (n = 1,179; excluded from this analysis). The study population was divided according to LVEF strata to investigate its impact on clinical outcomes.

RESULTS

The risk of all-cause mortality and the composite endpoint of aortic valve replacement or repair (AVR) and all-cause mortality increased when LVEF was <60% in the whole cohort as well as in the AS and AR groups, and when LVEF was <55% in MAVD group. In multivariable analysis, LVEF strata were significantly associated with increased rate of mortality (LVEF 50%-59%: HR: 1.83 [95% CI: 1.09-3.07]; P = 0.022; LVEF 30%-49%: HR: 1.97 [95% CI: 1.13-3.41]; P = 0.016; LVEF <30%: HR: 4.20 [95% CI: 2.01-8.75]; P < 0.001; vs LVEF 60%-70%, reference group).

CONCLUSIONS

In BAV patients, the risk of adverse clinical outcomes increases significantly when the LVEF is <60%. These findings suggest that LVEF cutoff values proposed in the guidelines to indicate intervention should be raised from 50% to 60% in AS or AR and 55% in MAVD.

Interaction between sex and left ventricular reverse remodeling and its association with outcomes after transcatheter aortic valve implantation

Women with severe aortic stenosis (AS) have better long-term prognosis after transcatheter aortic valve implantation (TAVI) compared to men. Whether this is caused by sex-related differences in left ventricular (LV) reverse remodeling after TAVI is unknown. Patients with severe AS who underwent transfemoral TAVI between 2007 and 2018 were selected. LV dimensions, volumes, and ejection fraction (LVEF) were assessed by transthoracic echocardiography before TAVI and at 6 and 12 months follow-up after TAVI. LV reverse remodeling was defined as the percentual LV mass index (LVMi) reduction compared to baseline. The primary outcome was all-cause mortality. A total of 459 patients (80 ± 8 years; 52% male) were included. At 6 and 12 months follow-up, both sexes showed significant reductions in LV volumes and LVMi accompanied by improvement in LVEF, without significant differences between the sexes over time. During a median follow-up of 2.8 [IQR 1.9-4.3] years, 181 (39%) patients died. Women showed better outcomes compared to men (log-rank p = 0.024). In addition, male sex was independently associated with all-cause mortality in multivariable Cox regression (HR 1.423, 95% CI 1.039-1.951, p = 0.028). No association was observed between the interaction of percentual LVMi reduction and sex with outcomes (p = 0.64). Men and women with severe AS had similar improvement in LVEF, and similar reductions in LV volumes and LVMi at 6 and 12 months after TAVI. Women showed better survival after TAVI as compared to men. The superior outcomes noted in women after TAVI are not associated with sex differences in LV reverse remodeling.

Prevalence and Prognostic Implications of Discordant Grading and Flow-Gradient Patterns in Moderate Aortic Stenosis

BACKGROUND

The prognostic implications of discordant grading in severe aortic stenosis (AS) are well known. However, the prevalence of different flow-gradient patterns and their prognostic implications in moderate AS are unknown.

OBJECTIVES

The purpose of this study was to investigate the occurrence and prognostic implications of different flow-gradient patterns in patients with moderate AS.

METHODS

Patients with moderate AS (aortic valve area >1.0 and ≤1.5 cm²) were identified and divided in 4 groups based on transvalvular mean gradient (MG), stroke volume index (SVi), and left ventricular ejection fraction (LVEF): concordant moderate AS (MG ≥20 mm Hg) and discordant moderate AS including 3 subgroups: normal-flow, low-gradient moderate AS (MG <20 mm Hg, SVi ≥35 mL/m², and LVEF ≥50%); "paradoxical" low-flow, low-gradient moderate AS (MG <20 mm Hg, SVi <35 mL/m², and LVEF ≥50%) and "classical" low-flow, low-gradient moderate AS (MG <20 mm Hg and LVEF <50%). The primary endpoint was all-cause mortality.

RESULTS

Of 1,974 patients (age 73 ± 10 years, 51% men) with moderate AS, 788 (40%) had discordant grading, and these patients showed significantly higher mortality rates than patients with concordant moderate AS (P < 0.001). On multivariable analysis, "paradoxical" low-flow, low-gradient (HR: 1.458; 95% CI: 1.072-1.983; P = 0.014) and "classical" low-flow, low-gradient (HR: 1.710; 95% CI: 1.270-2.303; P < 0.001) patterns but not the normal-flow, low-gradient moderate AS pattern were independently associated with all-cause mortality.

CONCLUSIONS

Discordant grading is frequently (40%) observed in patients with moderate AS. Low-flow, low-gradient patterns account for an important proportion of the discordant cases and are associated with increased mortality. These findings underline the need for better phenotyping patients with discordant moderate AS.

Left Ventricular Global Longitudinal Strain in Patients with Moderate Aortic Stenosis

Moderate aortic stenosis (AS) is associated with an increased risk for adverse events. Although reduced left ventricular (LV) global longitudinal strain (GLS) is associated with worse outcomes in patients with severe AS, its prognostic value in patients with moderate AS is unknown. The aim of this study was to investigate the prognostic implications of LV GLS in patients with moderate AS.

METHODS

LV GLS was evaluated using speckle-tracking echocardiography in patients with moderate AS (aortic valve area 1.0-1.5 cm²) and reported as absolute (i.e., positive) values. Patients were divided into three groups: LV ejection fraction (LVEF) < 50% (group 1), LVEF ≥ 50% but LV GLS < 16% (group 2), and LVEF ≥ 50% and LV GLS ≥ 16% (group 3). The LV GLS value of 16% was based on spline curve analysis. The primary end point was all-cause mortality.

RESULTS

A total of 760 patients (mean age, 71 ± 12 years; 61% men) were analyzed. During a median follow-up period of 50 months (interquartile range, 26-94 months), 257 patients (34%) died. Patients with LVEF < 50% and LVEF ≥ 50% but LV GLS < 16% showed significantly higher mortality rates at 1-, 3-, and 5-year follow-up (82%, 71%, and 58%; and 92%, 77%, and 58%, respectively) compared with those with LVEF ≥ 50% and LV GLS ≥ 16% (96%, 91%, and 85%, respectively; P < .001). Long-term outcomes were not different between patients with LVEF < 50% and those with LVEF ≥ 50% but LV GLS < 16% (P = .592). LV GLS discriminated higher risk patients even among those with LVEF ≥ 60% (P < .001) or those who were asymptomatic (P < .001). On multivariable analysis, LVEF < 50% (hazard ratio, 2.384; 95% CI, 1.614-3.522; P < .001) and LVEF ≥ 50% but LV GLS < 16% (hazard ratio, 2.467; 95% CI, 1.802-3.378; P < .001) were independently associated with all-cause mortality.

CONCLUSIONS

In patients with moderate AS, reduced LV GLS is associated with an increased risk for all-cause mortality, even if LVEF is still preserved.

Sex-Related Differences in Medically Treated Moderate Aortic Stenosis

Background

Recent data showed poor long-term survival in patients with moderate AS. Although sex differences in left ventricular (LV) remodeling and outcome are well described in severe AS, it has not been evaluated in moderate AS.

Methods

In this retrospective, multicenter study, patients with a first diagnosis of moderate AS diagnosed between 2001 and 2019 were identified. Clinical and echocardiographic parameters were recorded at baseline and compared between men and women. Patients were followed up for the primary endpoint of all-cause mortality with censoring at the time of aortic valve replacement.

Results

A total of 1895 patients with moderate AS (age 73 ± 10 years, 52% male) were included. Women showed more concentric hypertrophy and had more pronounced LV diastolic dysfunction than men. During a median follow-up of 34 (13-60) months, 682 (36%) deaths occurred. Men showed significantly higher mortality rates at 3- and 5-year follow-up (30% and 48%, respectively) than women (26% and 39%, respectively) (p = 0.011). On multivariable analysis, male sex remained independently associated with mortality (hazard ratio 1.209; 95% CI: 1.024-1.428; p = 0.025). LV remodeling (according to LV mass index) was associated with worse outcomes (hazard ratio 1.003; CI: 1.001-1.005; p = 0.006), but no association was observed between the interaction of LV mass index and sex with outcomes.

Conclusions

LV remodeling patterns are different between men and women having moderate AS. Male sex is associated with worse outcomes in patients with medically treated moderate AS. Further studies investigating the management of moderate AS in a sex-specific manner are needed.

Prognostic implications of left ventricular diastolic dysfunction in moderate aortic stenosis

OBJECTIVE

To investigate the prognostic impact of left ventricular (LV) diastolic dysfunction in patients with moderate aortic stenosis (AS) and preserved LV systolic function.

METHODS

Patients with a first diagnosis of moderate AS (aortic valve area >1.0 and ≤1.5 cm²) and preserved LV systolic function (LV ejection fraction ≥50%) were identified. LV diastolic function was evaluated using echocardiographic criteria according to the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines. Clinical outcomes were defined as all-cause mortality and a composite of all-cause mortality and aortic valve replacement (AVR).

RESULTS

Of 1247 patients (age 74±10 years, 47% men), 535 (43%) had LV diastolic dysfunction at baseline. Patients with LV diastolic dysfunction showed significantly higher mortality rates at 1-year, 3-year and 5-year follow-up (13%, 30% and 41%, respectively) when compared with patients with normal LV diastolic function (6%, 17% and 29%, respectively) (p<0.001). On multivariable analysis, LV diastolic dysfunction was independently associated with all-cause mortality (HR 1.368; 95% CI 1.085 to 1.725; p=0.008) and the composite endpoint of all-cause mortality and AVR (HR 1.241; 95% CI 1.035 to 1.488; p=0.020).

CONCLUSIONS

LV diastolic dysfunction is independently associated with all-cause mortality and the composite endpoint of all-cause mortality and AVR in patients with moderate AS and preserved LV systolic function. Assessment of LV diastolic function therefore contributes significantly to the risk stratification of patients with moderate AS. Future clinical trials are needed to investigate whether patients with moderate AS and LV diastolic dysfunction may benefit from earlier valve intervention.

Prognostic implications of left ventricular diastolic dysfunction in moderate aortic stenosis

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): ESC Training Grant App000064741

Background

Moderate aortic stenosis (MAS) is associated with an increased risk of adverse events. Although left ventricular (LV) diastolic dysfunction (DDF) has shown to carry an unfavorable prognosis in severe AS, the prognostic value of LV DDF in MAS has not been investigated.

Purpose

To investigate the prognostic impact of LV DDF in patients with MAS and preserved LV ejection fraction (EF).

Methods

LV diastolic function was evaluated in patients with MAS (aortic valve area &gt;1.0 and ≤1.5cm2)  and preserved LVEF (≥50%) using echocardiography according to the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines. Clinical outcomes were defined as all-cause mortality and a composite endpoint of all-cause mortality and aortic valve replacement (AVR).

Results

Of 1247 patients (age 74 ± 10 years, 47% men) with MAS and preserved LVEF, 396 (32%) had normal diastolic function, 316 (25%) had indeterminate diastolic function and 535 (43%) had DDF. Patients with DDF were more likely to be female, had more comorbidities (hypertension, atrial fibrillation, chronic kidney disease) and were more symptomatic (NYHA ≥2) than patients with normal diastolic function. Patients with DDF also had smaller aortic valve area and higher peak aortic velocities than patients with normal/indeterminate diastolic function. During a median follow-up of 53 (26 – 81) months, 484 (39%) patients died. For the composite endpoint, 770 patients (62%) underwent AVR (n = 376) or died (n = 394) during a median follow-up of 37 (IQR 15 – 62) months. Patients with DDF had significantly lower survival rates (p &lt;0.001) and event-free survival rates (p = 0.015) compared to patients with normal/indeterminate diastolic function (Figure 1). On multivariable analysis, DDF was independently associated with all-cause mortality (HR: 1.368; 95% CI: 1.085 – 1.725; p = 0.008) and the composite endpoint of all-cause mortality and AVR (HR: 1.241; 95% CI: 1.035 – 1.488; p = 0.020) (Figure 2).

Conclusion

LV DDF is associated with worse outcomes in patients with MAS. Assessment of LV diastolic function may contribute significantly to risk stratification of patients with MAS. Abstract Figure.  Abstract Figure.

Prognostic value of left ventricular global longitudinal strain in patients with moderate aortic stenosis

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): ESC Training Grant App000064741

Background

Impaired left ventricular (LV) global longitudinal strain (GLS) is associated with worse outcomes in patients with severe aortic stenosis, but its prognostic value in patients with moderate aortic stenosis (MAS) is largely unknown.

Purpose

To investigate the prognostic implications of LV GLS in patients with MAS and preserved LV ejection fraction (EF).

Methods

LV GLS was evaluated by speckle tracking echocardiography in 621 patients (age 71 ± 12 years, 59% men) with MAS (aortic valve area 1.0 – 1.5cm2) and preserved LVEF (≥50%). Impaired LV GLS was defined as an LV GLS value &lt;16%, based on spline curve analysis (i.e. where the hazard ratio for all-cause mortality was ≥1). Clinical outcomes were defined as all-cause mortality and a composite endpoint of all-cause mortality and aortic valve replacement.

Results

Patients with LV GLS &lt;16% (n = 282) were significantly older, more likely to be male and had more comorbidities (diabetes mellitus, atrial fibrillation, more impaired renal function) compared to patients with LV GLS ≥16% (n = 339). In terms of echocardiographic data, patients with LV GLS &lt;16% had larger LV volumes, lower LVEF and higher E/e’. During a median follow-up of 53 (27 – 102) months, 199 (32%) patients died. For the composite endpoint, 409 patients (66%) underwent AVR (n = 290) or died (n = 119) during a median follow-up of 29 (IQR 14 – 54) months. Patients with LV GLS &lt;16% experienced significantly lower survival rates (p &lt; 0.001) and event-free survival rates (p = 0.001) compared to patients with LV GLS ≥16% (Figure 1). On multivariable analysis, LV GLS was independently associated with all-cause mortality (HR 2.442; 95% CI: 1.762 – 3.384; p &lt; 0.001) and the composite endpoint of all-cause mortality and aortic valve replacement  (HR 1.862; 95% CI: 1.498 – 2.315; p = 0.040) (Figure 2).

Conclusions

In patients with MAS and preserved LVEF, reduced LV GLS is associated with an increased risk of all-cause mortality and the composite endpoint of all-cause mortality and AVR. Assessment of LV GLS may be useful in the risk stratification of these patients. Abstract Figure. Kaplan-Meier curves  Abstract Figure. Cox regression analysis

Left ventricular remodeling patterns in patients with moderate aortic stenosis

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): ESC Training Grant App000064741

Background

Moderate aortic stenosis (MAS) is associated with an increased risk of adverse events. Although left ventricular (LV) adverse remodeling is associated with worse outcomes in patients with severe AS, the prognostic significance of different patterns of LV remodeling in MAS has not been investigated.

Purpose

To investigate the association between different patterns of LV remodeling on outcomes in patients with MAS.

Methods

Patients with MAS (aortic valve area &gt;1.0 and ≤1.5cm2) were stratified into 4 groups according to the pattern of LV remodeling: normal geometry (NG), concentric remodeling (CR), concentric hypertrophy (CH) or eccentric hypertrophy (EH). Clinical outcomes were defined as all-cause mortality and a composite of all-cause mortality and aortic valve replacement (AVR).

Results

Of 1931 patients (age 73 ± 10 years, 52% men) with MAS, 344 (18%) had NG, 469 (24%) CR, 698 (36%) CH and 420 (22%) EH. Patients with CH were more likely to be female, had more hypertension, were more symptomatic (NYHA ≥III) and had more pronounced LV diastolic dysfunction, whereas patients with EH had more coronary artery disease, were more symptomatic (NYHA ≥III) and had lower LV ejection fraction than patients with NG. Patients with CH had higher aortic mean pressure gradients and peak aortic jet velocities than patients with NG. During a median follow-up of 51 (IQR 25 - 83) months, 833 (43%) patients died. For the composite endpoint, 1286 (67%) patients underwent AVR (n = 613) or died (n = 673) during a median follow-up of 35 (IQR 14 - 60) months. Patients with CH and EH had significantly lower survival rates (p &lt; 0.001; Figure 1) and event-free survival rates (p = 0.004) compared to patients with NG/CR. On multivariable analysis, CH was independently associated with all-cause mortality (HR:1.267; 95% CI:1.024 – 1.568; p = 0.029), whereas both CH (HR:1.293; 95% CI:1.090 – 1.533; p = 0.003) and EH (HR:1.222; 95% CI:1.013 – 1.474; p = 0.036) were associated with the composite endpoint of AVR and all-cause mortality (Figure 2).

Conclusions

In patients with MAS, different patterns of LV remodeling are observed with CH being independently associated with an increased risk of all-cause mortality. Risk stratification according to the different patterns of LV remodeling may help to identify patients with MAS who are at increased risk of adverse events and may benefit from closer follow-up. Abstract Figure. Kaplan-Meier curves  Abstract Figure. Cox regression analysis

OUP accepted manuscript

Aims 

Methods and results 

Conclusion 

Left ventricular remodelling in bicuspid aortic valve disease

AIMS

Characterization of left ventricular (LV) geometric pattern and LV mass could provide an important insight into the pathophysiological adaptations of the LV to pressure and/or volume overload in patients with bicuspid aortic valve (BAV) and significant (≥moderate) aortic valve (AV) disease. This study aimed to characterize LV remodelling and its prognostic impact in patients with BAV according to the predominant type of valvular dysfunction.

METHODS AND RESULTS

In this international, multicentre BAV registry, 1345 patients [51.0 (37.0-63.0) years, 71% male] with significant AV disease were identified. Patients were classified as having isolated aortic stenosis (AS) (n = 669), isolated aortic regurgitation (AR) (n = 499) or mixed aortic valve disease (MAVD) (n = 177). LV hypertrophy was defined as a LV mass index >115 g/m2 in males and >95 g/m2 in females. LV geometric pattern was classified as (i) normal geometry: no LV hypertrophy, relative wall thickness (RWT) ≤0.42, (ii) concentric remodelling: no LV hypertrophy, RWT >0.42, (iii) concentric hypertrophy: LV hypertrophy, RWT >0.42, and (iv) eccentric hypertrophy: LV hypertrophy, RWT ≤0.42. Patients were followed-up for the endpoints of event-free survival (defined as a composite of AV repair/replacement and all-cause mortality) and all-cause mortality. Type of AV dysfunction was related to significant variations in LV remodelling. Higher LV mass index, i.e. LV hypertrophy, was independently associated with the composite endpoint for patients with isolated AS [hazard ratio (HR) 1.08 per 25 g/m2, 95% confidence interval (CI) 1.00-1.17, P = 0.046] and AR (HR 1.19 per 25 g/m2, 95% CI 1.11-1.29, P < 0.001), but not for those with MAVD. The presence of concentric remodelling, concentric hypertrophy and eccentric hypertrophy were independently related to the composite endpoint in patients with isolated AS (HR 1.54, 95% CI 1.06-2.23, P = 0.024; HR 1.68, 95% CI 1.17-2.42, P = 0.005; HR 1.59, 95% CI 1.03-2.45, P = 0.038, respectively), while concentric hypertrophy and eccentric hypertrophy were independently associated with the combined endpoint for those with isolated AR (HR 2.49, 95% CI 1.35-4.60, P = 0.004 and HR 3.05, 95% CI 1.71-5.45, P < 0.001, respectively). There was no independent association observed between LV remodelling and the combined endpoint for patients with MAVD.

CONCLUSIONS

LV hypertrophy or remodelling were independently associated with the composite endpoint of AV repair/replacement and all-cause mortality for patients with isolated AS and isolated AR, although not for patients with MAVD.

Moderate aortic stenosis: importance of symptoms and left ventricular ejection fraction

AIMS

The aim of this study is to investigate the independent determinants of survival in patients with moderate aortic stenosis (AS), stratified by severity of symptoms and left ventricular ejection fraction (LVEF).

METHODS AND RESULTS

Patients with a first diagnosis of moderate AS (aortic valve area >1.0 and ≤1.5 cm2) were identified. Patients were stratified by New York Heart Association (NYHA) functional class (NYHA I, NYHA II, or NYHA III-IV) and LVEF (LVEF ≥60%, LVEF 50-59%, or LVEF <50%) at the time of moderate AS diagnosis. The primary endpoint was all-cause mortality, while the secondary endpoint included all-cause mortality and aortic valve replacement. Of 1961 patients with moderate AS (mean age 73 ± 10 years, 51% men), 1108 (57%) patients were in NYHA class I, while 527 (27%) and 326 (17%) patients had symptoms of NYHA class II and III-IV, respectively. Regarding LVEF, 1032 (53%) had LVEF ≥60%, 544 (28%) LVEF 50-59%, and 385 (20%) LVEF <50%. During a median follow-up of 50 (23-82) months, 868 (44%) patients died. On multivariable analysis, NYHA class II [hazard ratio (HR): 1.633; 95% confidence interval (CI): 1.431-1.864; P < 0.001], NYHA class III-IV (HR: 2.084; 95% CI: 1.797-2.417; P < 0.001), LVEF 50-59% (HR: 1.194; 95% CI: 1.013-1.406; P = 0.034), and LVEF <50% (HR: 1.694; 95% CI: 1.417-2.026; P < 0.001) were independently associated with increased mortality.

CONCLUSION

Moderate AS is associated with poor long-term survival. Baseline symptom severity and LVEF are associated with worse outcomes in these patients. Patients with low-normal LVEF (<60%) and mild symptoms (NYHA II) already have an increased risk of adverse events.

Assessment of left atrial electro-mechanical delay to predict atrial fibrillation in hypertrophic cardiomyopathy

AIMS

Atrial fibrillation (AF) is frequently observed in hypertrophic cardiomyopathy (HCM) and is associated with poor clinical outcome. Total atrial conduction time, estimated by tissue Doppler imaging (TDI), the so-called PA-TDI duration, reflects the left atrial (LA) structural and electrical remodelling. The aim of this study was to evaluate the association between PA-TDI and new-onset AF in patients with HCM.

METHODS AND RESULTS

From a large cohort of patients with HCM, 208 patients (64% male, mean age 53 ± 14 years) without AF were selected. PA-TDI duration was measured from the onset P wave on electrocardiogram to the peak A' wave of the lateral LA wall using TDI. The incidence of new-onset AF was 20% over a median follow-up of 7.3 (3.5-10.5) years. Patients with incident AF had longer PA-TDI duration when compared with patients without AF (133.7 ± 23.0 vs. 110.5 ± 30.0 ms, P < 0.001). PA-TDI duration was independently associated with new-onset AF (hazard ratio: 1.03, 95% confidence interval: 1.01-1.05, P < 0.001).

CONCLUSION

Prolonged PA-TDI duration was independently associated with new-onset AF in patients with HCM. This novel parameter could be useful to risk-stratify patients with HCM who are at risk of having AF.

Discordant severity criteria in patients with moderate aortic stenosis: prognostic implications

Background

The criteria to define the grade of aortic stenosis (AS)—aortic valve area (AVA) and mean gradient (MG) or peak jet velocity—do not always coincide into one grade. Although in severe AS, this discrepancy is well characterised, in moderate AS, the phenomenon of discordant grading has not been investigated and its prognostic implications are unknown.

Objectives

To investigate the occurrence of discordant grading in patients with moderate AS (defined by an AVA between 1.0 cm² and 1.5 cm² but with an MG <20 mm Hg) and how these patients compare with those with concordant grading moderate AS (AVA between 1.0 cm² and 1.5 cm² and MG ≥20 mm Hg) in terms of clinical outcomes.

Methods

From an ongoing registry of patients with AS, patients with moderate AS based on AVA were selected and classified into discordant or concordant grading (MG <20 mm Hg or ≥20 mm Hg, respectively). The clinical endpoint was all-cause mortality.

Results

Of 790 patients with moderate AS, 150 (19.0%) had discordant grading, moderate AS. Patients with discordant grading were older, had higher prevalence of previous myocardial infarction and left ventricular (LV) hypertrophy, larger LV end-diastolic and end-systolic volume index, higher LV filling pressure and lower LV ejection fraction and stroke volume index as compared with their counterparts. After a median follow-up of 4.9 years (IQR 3.0–8.2), patients with discordant grading had lower aortic valve replacement rates (26.7% vs 44.1%, p<0.001) and higher mortality rates (60.0% vs 43.1%, p<0.001) as compared with patients with concordant grading. Discordant grading moderate AS, combined with low LV ejection fraction, presented the higher risk of mortality (HR 2.78 (2.00–3.87), p<0.001).

Conclusion

Discordant-grading moderate AS is not uncommon and, when combined with low LV ejection fraction, is associated with high risk of mortality.

P5582Predicting the clinical outcomes in moderate aortic stenosis: implementation of the newly proposed staging classification

Background

While symptomatic severe aortic stenosis (AS) carries a worse prognosis and early intervention is favoured, it is always assumed that patients with moderate AS are more stable and their disease progression can be monitored yearly. However, it is known that patients with moderate AS have a higher risk of cardiovascular events but is unclear if other factors may also affect the overall prognosis.

Purpose

In this multicentre registry of patients with moderate AS, the prognostic value of a new staging classification on the extent of cardiac damage was examined.

Methods

Based on the echocardiographic findings at the time of diagnosis of moderate AS (valve area >1.0 and ≤1.5 cm2), they were re-classified into five stages depending on the extra-aortic valvular cardiac damage: no signs of cardiac damage (Stage 0), left ventricular (LV) damage [LV ejection fraction <50%, LV mass index >95 g/m2 for women or >115 g/m2 for men or E/e' >14] (Stage 1), mitral valve or left atrial (LA) damage [LA volume index >34 ml/m2 or mitral regurgitation ≥grade 3 or presence of atrial fibrillation] (Stage 2), tricuspid valve or pulmonary artery vasculature damage [systolic pulmonary arterial pressure ≥60 mmHg or tricuspid regurgitation ≥grade 3] (Stage 3), or right ventricular damage [tricuspid annular plane systolic excursion <17 mm] (Stage 4). The clinical endpoint was all-cause mortality. The association between the extent of cardiac damage and all-cause mortality was assessed by the Kaplan Meier method using log-rank test.

Results

Of the included 522 patients with moderate AS (age 71±11 years, 54% males), 12% (63) of patients were re-classified as Stage 0, 30% (157) in Stage 1, 47% (245) in Stage 2, 6% (31) in Stage 3 and 5% (26) in Stage 4. During follow-up, 43% (226) of patients underwent surgical or transcatheter aortic valve replacement. Over a median follow-up of 6.2 [interquartile range 3.2–9.0] years, 254 (49%) patients died. The cumulative event rates for all-cause mortality increased with increasing stage, particularly for Stages ≥2: 39% for Stage 0, 55% for Stage 1, 67% for Stage 2, 68% for Stage 3 and 57% for Stage 4, respectively (Figure, log-rank test p=0.001).

Cumulative death rates after re-staging

Conclusion

In a real-world registry of patients with moderate AS patients, worsening extra-aortic valvular cardiac damage portends a worse long-term prognosis.

P2465Assessment of left atrial electro-mechanical delay to predict atrial fibrillation in hypertrophic cardiomyopathy

Background

Left atrial remodelling in hypertrophic cardiomyopathy (HCM) is recognized as the main contributor to the development of atrial fibrillation (AF). It is well reported that the occurrence of AF in HCM increases both morbidity and mortality. Therefore, early recognition of AF is essential. Due to its often silent and paroxysmal nature, the diagnosis can be missed.

Purpose

PA-TDI, representing total atrial conduction time, reflects the left atrial structural and electrical remodelling. We sought to evaluate the association between this novel non-invasive echocardiographic parameter and AF in patients with HCM.

Methods

The electronic charts of patients with HCM and no previous history of AF from 1993 to 2018 were retrospectively analysed. PA-TDI was measured offline using pulsed wave tissue Doppler imaging with the sample volume placed on the lateral wall of the left atrium just above the mitral annulus in an apical 4-chamber view. The time interval was determined from the onset of P wave on surface ECG to the peak of the a' wave of the left atrial tissue Doppler tracing.

Results

There were 208 patients (64% male) with a mean age of 53±14 years in this study. The incidence of AF was 20% over a median follow-up of 56.3 (IQR 18.4–84.5) months. Patients who developed AF, had higher baseline PA-TDI intervals when in sinus rhythm (134±23 ms vs 111±30 ms, P<0.001) than those who remained free from AF. The cut-off value of PA-TDI duration was the median at 115 ms. A PA-TDI ≥115 ms was independently associated with new onset AF (HR: 2.5, 95% CI: 1.1–5.5, P=0.02) after correcting for age, left atrial diameter and E/e'.

Conclusion

A prolonged PA-TDI was strongly associated with the development of AF in patients with HCM. This parameter may be useful to risk-stratify patients with HCM who are at risk of having AF.

P3694Discordant criteria in moderate aortic stenosis patients: prognostic implications

Background

The frequency of discordant mean valve gradient (MG) and aortic valve area (AVA) in patients with moderate aortic stenosis (AS) has not been investigated.

Objectives

Determine the occurrence of discordant gradient in patients with moderate AS (defined by MG <20 mmHg), and how these patients compare with concordant gradient moderate AS (MG >20 mmHg) in terms of patients' characteristics and the impact on long term prognosis.

Methods

Based on the echocardiographic findings at the time of diagnosis of moderate AS (valve area >1.0 and ≤1.5 cm2), they were re-classified into discordant or concordant gradients, MG <20 mmHg or >20 mmHg, respectively. The clinical endpoint was all-cause mortality.

Results

Of 522 patients with moderate AS, 95 (18.2%) had discordant gradient moderate AS (MG <20 mmHg). Patients with discordant mean gradient were older, had higher prevalence of previous myocardial infarct, larger left ventricular (LV) end-diastolic volume index, lower LV ejection fraction (EF), stroke volume index and higher LV filling pressure. Compared to patients with concordant gradients, these patients had higher mortality rates (57.9% vs 46.6%, p=0.05) and lower aortic valve replacement rates (33.7% vs 54.9%, p<0.001) during a median follow-up of 6.2 [IQR 3.2–9.0] years. The results of Cox regression analysis are shown on the table.

Cox proportional hazard analysis All-cause mortality Univariate analysis Multivariate analysis Hazard ratio (95% CI) P value Hazard ratio (95% CI) P value Age (per 1 year increase) 1.05 (1.03–1.06) <0.001 1.04 (1.02–1.06) <0.001 Diabetes (yes/no) 1.34 (1.03–1.74) 0.031 1.33 (0.97–1.82) 0.072 Previous myocardial infarction (yes/no) 1.73 (1.29–2.34) <0.001 1.01 (0.70–1.46) 0.980 eGFR <60 ml/min/1.73m2 (yes/no) 2.15 (1.68–2.76) <0.001 1.71 (1.25–2.33) 0.001 Left ventricular hypertrophy (yes/no) 1.74 (1.31–2.30) <0.001 1.50 (1.07–2.09) 0.018 Indexed LA volume (per 1 mL/m2 increase) 1.005 (1.001–1.009) 0.008 1.006 (1.001–1.012) 0.040 Tricuspid regurgitation >moderate (yes/no) 2.02 (1.29–3.16) 0.002 1.36 (0.73–2.54) 0.337 Discordant moderate AS (yes/no) 1.81 (1.34–2.45) <0.001 1.42 (1.01–2.01) 0.049 AS, aortic stenosis; CI, confidence interval; eGFR, estimated glomerular filtration rate; HR, hazard ratio; LA, Left atrial.

Conclusion

Discrepant aortic mean gradient in moderate AS is not uncommon and occurs more often in older patients, with higher LV filling pressure and lower EF and stroke volume index. The lower gradient values lead to underestimation of AS severity, and is associated with greater cardiac extra-valvular damage and higher mortality.

Early echocardiographic predictors of increased left ventricular end-diastolic pressure three months after myocardial infarction in rats

Background

The objective of this study was to determine the early echocardiographic predictors of elevated left ventricular end-diastolic pressure (LVEDP) after a long follow-up period in the infarcted rat model.

Material/Methods

Five days and three months after surgery, sham and infarcted animals were subjected to transthoracic echocardiography. Regression analysis and receiver-operating characteristic (ROC) curve were performed for predicting increased LVEDP 3 months after MI.

Results

Among all of the variables, assessed 5 days after myocardial infarction, infarct size (OR: 0.760; CI 95% 0.563–0.900; p=0.005), end-systolic area (ESA) (OR: 0.761; CI 95% 0.564–0.900; p=0.008), fractional area change (FAC) (OR: 0.771; CI 95% 0.574–0.907; p=0.003), and posterior wall-shortening velocity (PWSV) (OR: 0.703; CI 95% 0.502–0.860; p=0.048) were predictors of increased LVEDP. The LVEDP was 3.6±1.8 mmHg in the control group and 9.4±7.8 mmHg among the infarcted animals (p=0.007). Considering the critical value of predictor variables in inducing cardiac dysfunction, the cut-off value was 35% for infarct size, 0.33 cm² for ESA, 40% for FAC, and 26 mm/s for PWSV.

Conclusions

Infarct size, FAC, ESA, and PWSV, assessed five days after myocardial infarction, can be used to estimate an increased LVEDP three months following the coronary occlusion.