Prognostic Impact of Low-Flow Severe Aortic Stenosis in Small-Body Patients Undergoing TAVR: The OCEAN-TAVI Registry

Objectives

This study aimed to analyze the prognostic impact of low-flow (LF) severe aortic stenosis in small-body patients undergoing transcatheter aortic valve replacement (TAVR).

Prognostic Impact of Left Ventricular Ejection Fraction in Patients With Severe Aortic Stenosis

Objectives

The aim of this study was to evaluate the prognostic impact of left ventricular ejection fraction (LVEF) in patients with severe aortic stenosis (AS).

Relationship Between Left Ventricular Ejection Fraction and Mortality in Asymptomatic and Minimally Symptomatic Patients With Severe Aortic Stenosis

Objectives

This study sought to determine the best left ventricular ejection fraction (LVEF) cutoff value to predict long-term mortality in patients with asymptomatic or minimally symptomatic severe aortic stenosis (AS) and LVEF ≥50% under conservative management and after surgical correction of AS.

Reduced Left Ventricular Ejection Fraction in Patients With Aortic Stenosis

Background

Left ventricular ejection fraction (LVEF) is reduced in a subset of patients with severe aortic stenosis (AS).

Distribution and Prognostic Significance of Left Ventricular Global Longitudinal Strain in Asymptomatic Significant Aortic Stenosis: An Individual Participant Data Meta-Analysis

Objectives

In this individual participant data meta-analysis on left ventricular global longitudinal strain (LVGLS), our objective was to: 1) describe its distribution; 2) identify the most predictive cutoff values; and 3) assess its impact on mortality in asymptomatic patients with significant aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF).

Clinical outcome following Transcatheter Aortic Valve Implantation in patients with impaired left ventricular systolic function

Objectives: To determine the prevalence of impaired left ventricular (LV) systolic function and its impact on the in‐hospital and long‐term outcome in patients who underwent Transcatheter Aortic Valve Implantation (TAVI). Background: Although impaired LV function may be considered a contra‐indication for aortic valve replacement, the hemodynamic characteristics of transcatheter valves may offer procedural and long‐term clinical benefit in such patients. Methods: 230 consecutive patients underwent TAVI with the Medtronic‐CoreValve System. Impaired LV function was defined by a Left Ventricular Ejection Fraction (LVEF) ≤ 35% (European Multicenter Study on Operative Risk Stratification and Long‐term Outcome in patients with Low‐Flow/Low‐Gradient Aortic Stenosis). Study endpoints were selected and defined according to the Valve Academic Research Consortium recommendations. Results: Compared with patients with a LVEF > 35% (n = 197), those with LVEF ≤ 35% (n = 33) were more often male (78.8 % vs. 46.7%, P < 0.001), more symptomatic (NYHA class III or IV, 97.0% vs. 77.2%, P = 0.008) and had a higher prevalence of prior coronary artery disease (63.6% vs. 43.1%, P = 0.029). The Logistic EuroSCORE was 14.8% and 22.8, respectively (P = 0.012). No difference was observed between the two groups in in‐hospital or 30‐day mortality (3.0% vs. 9.6%, P = 0.21), the Combined Safety Endpoint at 30 days (24.2% and 24.4%, P = 0.99) and survival free from readmission at one year (69.2% and 69.7%, P = 0.85). After adjustment, LVEF ≤ 35% was not associated with an increased risk of 30‐day mortality, in‐hospital complications and survival free from readmission at follow‐up. Conclusion: The immediate and long‐term outcome after TAVI did not differ between patients with an impaired and preserved LVEF. LVEF ≤ 35% did not predict adverse immediate and long‐term outcome. These findings suggest that TAVI should not be withheld in selected patients with impaired LV function. © 2011 Wiley Periodicals, Inc.     

Outcomes of Transcatheter Aortic Valve Replacement in Mixed Aortic Valve Disease

ObjectivesThe aim of this study was to compare outcomes after transcatheter aortic valve replacement (TAVR) in patients with pure aortic stenosis (AS) (i.e., no or trivial associated aortic regurgitation [AR]) with those in patients with AS and mild or more severe AR (i.e., mixed aortic valve disease [MAVD]).BackgroundTAVR is indicated in treating patients with severe AS. Limited data exist regarding the outcomes of TAVR in patients with MAVD.MethodsA total of 1,133 patients who underwent TAVR between January 2014 and December 2017 were included. The primary outcome was all-cause mortality. The comparison was adjusted to account for post-TAVR AR development in both groups. The secondary outcomes included composite endpoints of early safety and clinical efficacy as specified in the Valve Academic Research Consortium-2 criteria. Variables were compared using Mann-Whitney, chi-square, and Fisher exact tests, while Kaplan-Meier analyses were used to compare survival.ResultsA total of 688 patients (61%) had MAVD (median age 83 years , 43% women). Among these, 17% developed mild, 2% moderate, and <1% severe post-TAVR AR. Overall, patients with MAVD had better survival compared with patients with pure AS (p = 0.03). Among patients who developed post-TAVR AR, those in the MAVD group had better survival (p = 0.04). In contrast, in patients who did not develop post-TAVR AR, pre-TAVR AR did not improve survival (p = 0.11).ConclusionsPatients with MAVD who underwent TAVR had better survival compared with patients with pure AS. This is explained by the better survival of patients with MAVD who developed post-TAVR AR, likely due to left ventricular adaptation to AR.     

Long‐Term Outcome in Asymptomatic Patients with Severe Aortic Regurgitation,Normal Left Ventricular Ejection Fraction,and Severe Left Ventricular Dilatation

Background: Although the guidelines consider severe left ventricular (LV) dilatation a class IIaC indication for surgery in asymptomatic patients with severe aortic regurgitation (AR) and normal LV function, the optimal management remains controversial. We aimed to assess the LV enlargement, hypertrophy and function, and the outcomes in these patients by the presence of severe LV dilatation at baseline. Methods: From our 20‐year database, we identified all asymptomatic patients with severe AR and LV ejection fraction (EF) >50% and ≥2 echocardiograms ≥1 year apart. LV end‐diastolic diameter >70 mm or LV end‐systolic diameter >50 mm or LV end‐systolic diameter index >25 mm/m² defined severe LV dilatation. A composite end point included onset of symptoms or LV dysfunction. Results: Eighty‐four patients (52 ± 18 years, 61 men) were enrolled and followed‐up for 7.1 ± 5.1 years. Two groups were defined: 22 patients with and 62 patients without severe LV dilatation at baseline. The progression of LV dilatation and hypertrophy, and the LVEF at last exam were similar in both groups. Twelve of 22 and 34 of 62 patients (P = 0.59) reached the end point. Vasodilators did not modify the progression of LV enlargement/hypertrophy. Ten of 22 and 25 of 62 patients (P = 0.45) underwent surgery and had similar postoperative LV diameters, mass, EF. Conclusions: The progression of LV enlargement/hypertrophy and outcomes in asymptomatic patients with severe AR, normal LV function, and severe LV dilatation or the postoperative LV parameters were not influenced by the severe LV dilatation, suggesting that a close follow‐up could delay surgery in this population. (Echocardiography 2010;27:915‐922)     

Prognostic Value of Exercise-Stress Echocardiography in Asymptomatic Patients With Aortic Valve Stenosis

Objectives

This study sought to evaluate the prognostic value of mean pressure gradient (MPG) increase and peak systolic pulmonary artery pressure (SPAP) measured during exercise stress echocardiography in asymptomatic patients with aortic stenosis (AS).

Outcomes of patients with low‐pressure aortic gradient undergoing transcatheter aortic valve implantation

Background: The risk/benefit balance of transcatheter aortic valve implantation (TAVI) in patients with low‐gradient aortic stenosis (LGAS) remains to be well defined. Aim of the study was to investigate the impact of LGAS in patients undergoing TAVI. Methods: Medline, Cochrane Library, and Scopus were searched for articles reporting outcome of patients with LGAS undergoing TAVI. The primary endpoint was 12‐months all‐cause mortality and the secondary endpoint was 30‐day all‐cause mortality. Using event‐rates as dependent variable, a meta‐regression was performed to test for interaction between baseline clinical features (age, gender, diabetes mellitus, coronary artery disease, left ventricular ejection fraction (LVEF) and type of implanted valve) and transaortic gradient for the primary endpoint. Results: Eight studies with a total of 12,589 patients were included. Almost one‐third of the patients presented with LGAS (27.3%: 24.4–29.2). Median LVEF was 48% in patients with LGAS and 56% in patients with high‐gradient AS. Patients with LGAS were more likely to have diabetes mellitus, previous coronary artery disease, higher mean Logistic EuroSCORE, and lower EF. At 12 (12–16.6) months, low transaortic gradient emerged as independently associated with all‐cause death, both if evaluated as a dichotomous and continuous value (respectively OR 1.17; 1.11–1.23 and OR 1.02; 1–1.04, all CI 95%). Clinical variables, including EF did not affect this result. Conclusions: In a population of TAVI patients, LGAS appears to be independently related to dismal prognosis. © 2016 Wiley Periodicals, Inc.     

Assessment of Subclinical Left Ventricular Dysfunction in Aortic Stenosis

Left ventricular (LV) systolic dysfunction is an adverse consequence of the pressure overload of severe aortic stenosis (AS). The enlargement of the interstitial space with reactive fibrosis and subsequently with replacement fibrosis and cell death has been suggested to be the main driver of the transition to symptoms, heart failure, and adverse cardiovascular events even after aortic valve replacement (AVR). Early and accurate recognition of myocardial dysfunction offers the potential to optimize the timing of intervention in severe AS. In the asymptomatic patient, an LV ejection fraction (EF) cutpoint of <50% has been used for this purpose. However, in most asymptomatic patients, an LVEF <50% is uncommon, and patients with an LVEF of 50% to 59% fare almost as badly. Moreover, the presence of a small LV cavity, the reliability and automation of the global longitudinal strain (GLS) signal, and the independent prognostic role of GLS are reasons why GLS could be expected to be a better marker of subclinical LV dysfunction in these patients. This review seeks to define whether the existing EF cutoff in AS should be modified or whether GLS should replace it as the marker of subclinical LV dysfunction.     

Predictors of improvement in left ventricular function after initially successful angioplasty of unprotected left main coronary artery stenoses

BACKGROUND: Percutaneous coronary intervention (PCI) has been increasingly applied to unprotected left main coronary artery (LMCA) lesions, with varied procedural success and clinical outcomes. However, the effect of PCI on left ventricular performance is still unclear, and there are no clinical studies assessing factors that influence left ventricular ejection fraction (LVEF) in these cases. METHODS: Between April 1986 and August 2002, de novo PCI was performed for unprotected LMCA stenoses in 199 patients. Close clinical and angiographic follow-up were conducted after the procedure. RESULTS: One hundred eighty patients survived over six months and analysis of paired left ventriculography was possible in 175 patients. Improvement in LVEF was observed in the entire population (52.9?±?15.7% to 56.1?±?14.3%, p?= 0.048). The LVEF change was 6.7?± 9.5% (p?&lt;?0.01) in group with baseline LVEF?≤??50% and 0.7?±?6.7 % (p?=?NS) in group with LVEF?&gt;?50%. There was significant intergroup difference (p?&lt;?0.001). Patients with baseline diameter stenosis ≥60% had an improvement of 5.3?±?8.3% (p?&lt;?0.05) whereas those with stenosis?&lt;?60% had no improvement (2.0?±?8.4%, p?=?NS). CK-MB elevation ≥3 times normal after PCI had a significant inverse association with improvement in LVEF (p?&lt;?0.05). Multivariate analysis revealed baseline LVEF ≤?50% was the only independent predictor of improvement in LVEF (standard estimate?=?3.509, 95% CI: 2.164-4.854, p?&lt;?0.001). CONCLUSIONS: Successful PCI procedure is associated with significant improvement in LVEF, especially in patients with depressed left ventricular function. (Int J Cardiovasc Intervent 2004; 6: 119-127)     

Global longitudinal strain in relation to the severity of aortic stenosis: a two-dimensional speckle-tracking study

Background: Global longitudinal strain (GLS) measured by two‐dimensional speckle tracking imaging (2D‐STI) has been shown to be useful for assessing subtle change in left ventricular function in severe aortic stenosis (AS) patients with preserved left ventricular ejection fraction (LVEF). However, there is little information about the relation between the progression of AS and changes in GLS. The aim of this study was to evaluate the relation between the severity of valve stenosis and GLS measured by 2D‐STI in AS patients with normal LVEF. Methods: We studied 113 AS patients (age, 73.3 ± 8.8 years; male, 38%; aortic valve area (AVA), 1.0 ± 0.3 cm²; mean pressure gradient (PG), 33.8 ± 22.1 mmHg) with normal LVEF (≥50%) but without overt coronary artery disease. Patients were stratified into three groups (mild, moderate and severe AS), and the clinical characteristics and echocardiographic findings were compared among the groups. Using dedicated software, we measured GLS in the apical four‐chamber view. Results: LVEF was not significantly different among the three groups. However GLS showed significant differences in GLS among the three groups (mild: 17.1 ± 3.0%, moderate: 16.4 ± 3.0% and severe: 14.5 ± 3.9%, ANOVA P = 0.003). GLS was significantly correlated with AVA, mean PG, LVEF, LV mass index and early diastolic mitral annular velocity (e’). In multiple stepwise regression analysis, mean PG, LVEF and hypertension were independently associated with GLS (R²= 0.247, P = 0.0001). Conclusions: Despite unchanged LVEF, GLS gradually decreased as severity of AS increases. GLS measured by 2D‐STI might be useful to assess subtle changes in LV function in AS patients. (Echocardiography 2011;28:703‐708)     

Long-Term Outcomes in Patients With New Permanent Pacemaker Implantation Following Transcatheter Aortic Valve Replacement

Objectives

This study sought to evaluate the long-term clinical impact of permanent pacemaker implantation (PPI) after transcatheter aortic valve replacement (TAVR).

First-Phase Ejection Fraction Is a Powerful Predictor of Adverse Events in Asymptomatic Patients With Aortic Stenosis and Preserved Total Ejection Fraction

Objectives

This study investigated the prognostic value of first-phase ejection fraction (EF1) in patients with aortic stenosis (AS), a condition in which left ventricular dysfunction as measured by conventional indices is an indication for valve replacement.

Network Tomography for Understanding Phenotypic Presentations in Aortic Stenosis

Objectives

This study sought to build a patient?patient similarity network using multiple features of left ventricular (LV) structure and function in patients with aortic stenosis (AS). The study further validated the observations in an experimental murine model of AS.

Setting a benchmark for resource utilization and quality of care in patients undergoing transcatheter aortic valve implantation in Europe—Rationale and design of the international BENCHMARK registry

BackgroundThe use of transcatheter aortic valve implantation (TAVI) for treating aortic stenosis (AS) has increased exponentially in recent years. Despite the availability of clinical practice guidelines for the management of valvular heart disease, disparities in quality of care (QoC) for TAVI patients remain widespread across Europe. Tailored QoC measures will help to reduce resource utilization and improve patient outcomes without compromising patient safety. Using a clear set of QoC measures, the BENCHMARK registry aims to document the progress that can be achieved if such tailored QoC measures are implemented.MethodsThe BENCHMARK registry (BENCHMARK) is a non‐interventional, multicenter registry in patients with severe symptomatic AS undergoing TAVI with a 1‐ and 12‐months follow‐up. BENCHMARK will be conducted at 30 centers across Europe and will enroll a total of 2400 consecutive TAVI patients. Patients suffering from severe symptomatic AS who undergo TAVI with a balloon‐expandable transcatheter aortic valve will be included. The registry will comprise four phases: (1) a retrospective baseline evaluation phase; (2) an education phase; (3) an implementation phase; and (4) a prospective effect documentation phase (prospective phase). The registry''s primary objectives are to reduce the length of hospital stay and accelerate the post‐procedural patient recovery pathway, but without compromising safety. The study started in April 2021 and has an estimated completion date of May 2023.DiscussionBENCHMARK will establish QoC measures to reduce resource utilization, intensive care unit bed occupancy, and overall length of hospitalization with uncompromised patient safety post‐TAVI (ClinicalTrials.gov Identifier: {"type":"clinical-trial","attrs":{"text":"NCT04579445","term_id":"NCT04579445"}}NCT04579445).     

How the COVID-19 pandemic changed treatment of severe aortic stenosis: a single cardiac center experience

BackgroundCurrently, two effective therapeutic options for severe aortic stenosis (AS) are available, one catheter-based [transcatheter aortic valve implantation (TAVI)], the other open surgical approach [surgical aortic valve replacement (SAVR)]. The COVID-19 pandemic has limited the availability of medical procedures. The purpose of this cross-sectional study was to assess if this pandemic had any impact on the treatment strategy of severe AS in a single cardiac center.MethodsThis study involved AS patients treated in 3-month periods (February through April) over 3 consecutive years 2018, 2019 [defined as COV(–) group] and 2020 [COV(+)]. We assessed if there were any differences regarding patients’ clinical profile, applied therapeutic method, procedure complexity and early clinical outcomes.ResultsIn the years 2018 through 2019, approximately 50% of AS patients were treated classically (SAVR) while in 2020 this rate dropped to 34%. The preoperative clinical characteristic of TAVI subjects was comparable irrespective of the year. Regarding SAVR, more patients in COV(+) underwent urgent and more complex procedures. More of them were found in NYHA class III or IV, and had lower left ventricular ejection fraction (LVEF) (51.9%±14.4% vs. 58.3%±8.1%; P=0.021) than in COV(–) individuals. During the pandemic, a change in applied therapeutic methods and differences in patients’ clinical profile did not have an unfavorable impact on in-hospital mortality (2.0% before vs. 3.6% during pandemic) and morbidity. Of note, intubation time and in-hospital stay were significantly shorter (P<0.05) in 2020 (4.2 hours and 7.5 days) than in the previous years (7.5 hours and 9.0 days, respectively).ConclusionsThe coronavirus pandemic has changed substantially the management of severe AS. The shift into less invasive treatment method of AS patients resulted in shortening of in-hospital stay without compromise of short-term outcomes.     

二维斑点追踪技术评价老年重度退行性主动脉瓣狭窄并高血压患者左心室收缩功能

目的应用二维斑点追踪技术评价老年重度退行性主动脉瓣狭窄(AS)并高血压患者左心室心肌收缩功能的改变。方法收集LVEF>54%老年重度退行性AS患者58例,按照是否合并高血压,分为AS组28例和合并高血压组30例,收集健康体检者28例为对照组,检测血压和常规超声心动图数据,包括左心室舒张末期内径、左心室后壁厚度、室间隔厚度及左心室质量指数(LVMI);二维斑点追踪技术测量左心室整体收缩期峰值纵向应变(GLS)、圆周应变(GCS)、径向应变(GRS)及扭转角度(Rot)。结果合并高血压组收缩压、舒张压、Rot明显高于对照组和AS组(P<0.01)。对照组、AS组和合并高血压组室间隔厚度、LVMI、GCS逐渐增高,GLS逐渐减低(P<0.01)。AS组和合并高血压组左心室后壁厚度明显高于对照组(P<0.01),GRS明显低于对照组[(32.2±12.2)%,(29.2±9.6)%vs (41.7±11.3)%,P<0.01]。结论与LVEF>54%的老年重度退行性AS患者比较,合并高血压的老年重度退行性AS患者左心室心肌功能进一步减低。二维斑点追踪技术是一种评价心肌早期受损的敏感方法,为临床早期诊断和治疗提供依据。     

Changes in the Left Ventricular Ejection Fraction and Outcomes in Hospitalized Heart Failure Patients with Mid-range Ejection Fraction: A Prospective Observational Study

Objective Current clinical guidelines have proposed heart failure (HF) with mid-range ejection fraction (HFmrEF), defined as a left ventricular ejection fraction (LVEF) of 40-49%, but the proportion and prognosis of patients transitioning toward HF with a reduced LVEF (LVEF <40%, HFrEF) or HF with a preserved LVEF (LVEF ≥50%, HFpEF) are not fully clear. The present study prospectively evaluated the changes in the LVEF one year after discharge and the outcomes of hospitalized patients with HFmrEF. Methods We prospectively studied 259 hospitalized patients with HFmrEF who were discharged alive at our institutions between 2015 and 2019. Among them, 202 patients with HFmrEF who underwent echocardiography at the one-year follow-up were included in this study. Patient characteristics, echocardiographic data and all-cause death were collected. Results Eighty-seven (43%) patients transitioned to HFpEF (improved group), and 35 (17%) transitioned to HFrEF (worsened group). During a median follow-up of 33 months, 27 (13%) patients died. After adjustment, patients in the worsened group had an increased risk of all-cause mortality compared with those in the improved group [hazard ratio 7.02, 95% confidence interval (CI) 1.13-43.48]. The baseline LVEF (per 1% decrease) and tricuspid annular plane systolic excursion (per 1 mm decrease) were independent predictors of the worsened LVEF category (odds ratio 2.13, 95% CI 1.25-3.63 and odds ratio 1.31, 95% CI 1.01-1.70, respectively). Conclusion Our study showed that a worsened LVEF one year after discharge was associated with a poor prognosis in hospitalized patients with HFmrEF.