Abstract
Background
Tools are needed to identify patients at increased risk after transcatheter aortic
valve replacement (TAVR). Indexed stroke volume (SVi) is an echocardiographic measurement
that is used for low-gradient aortic stenosis. We studied whether low SVi is a high-risk
marker in patients with high-gradient aortic stenosis (HG-AS) and assessed the relationship
between SVi and left ventricle (LV) systolic function in contributing to this risk.
Methods
A total of 816 consecutive patients who underwent TAVR were screened, and only patients
with HG-AS were included. Low flow (LF) was defined as SVi ≤ 35 mL/m2. The primary endpoint was defined as a combination of all-cause mortality and readmission
with heart failure at 1 year.
Results
Of the 476 patients with HG-AS, 215 (45%) had LF. They had higher N-terminal pro b-type
natriuretic peptide (NTproBNP) (2565 [1037-5492] vs 1730 [818-3575], P = 0.006) and smaller indexed valve area (0.30 ± 0.10 vs 0.37 ± 0.10 cm2/m2, P < 0.001) when compared with normal flow patients. The primary endpoint was higher
in LF patients (hazard ratio, 1.49; 95% confidence interval, 1.01-2.21; P = 0.045). There were no statistical differences in the individual components of death
(13.0% vs 8.9%, P = 0.16) or heart failure (14.9% vs 10.1%, P = 0.12). When stratified according to LV function, low SVi was associated with future
adverse events in patients with reduced function (hazard ratio, 3.37; 95% confidence
interval, 1.26-8.98; P = 0.015) with comparable clinical outcomes in those with preserved function. LF was
an independent predictor of adverse events in the reduced LV function subgroup.
Conclusions
SVi can further characterize patients with HG-AS and may help to identify those who
are at increased risk after TAVR.
Résumé
Contexte
Des outils sont nécessaires pour dépister les patients exposés à un risque accru à
la suite d’un remplacement valvulaire aortique par cathéter (RVAC). Le volume systolique
indexé (VSI) est une mesure échocardiographique utilisée dans les cas de sténose aortique
à faible gradient. Nous avons vérifié si un faible VSI était un marqueur de risque
accru chez les patients présentant une sténose aortique à gradient élevé et avons
évalué comment la relation entre le VSI et la fonction systolique ventriculaire gauche
pouvait contribuer à ce risque.
Méthodologie
Au total, 816 patients consécutifs ayant subi un RVAC ont été sélectionnés, dont seuls
les patients présentant une sténose aortique à gradient élevé ont été inclus dans
l’étude. Un faible débit était défini par un VSI ≤ 35 ml/m2. L’étude avait un paramètre d’évaluation principal combiné englobant la mortalité
toutes causes confondues et la réhospitalisation pour cause d’insuffisance cardiaque
après 1 an.
Résultats
Sur les 476 patients atteints de sténose aortique à gradient élevé, 215 (45 %) présentaient
un faible débit. Comparativement aux patients au débit normal, leur taux de NT-proBNP
(propeptide natriurétique de type B N-terminal) était plus élevé (2 565 [1 037-5 492]
vs 1 730 [818-3 575]; p = 0,006) et leur surface valvulaire indexée, plus petite (0,30 ± 0,10 vs 0,37 ± 0,10
cm2/m2; p < 0,001). Le paramètre d’évaluation principal a été atteint plus fréquemment chez
les patients qui présentaient un faible débit (rapport des risques instantanés : 1,49;
intervalle de confiance [IC] à 95 % : de 1,01 à 2,21; p = 0,045). Il n’y avait pas de différence significative en ce qui a trait aux composantes
individuelles de la mortalité (13,0 % vs 8,9 %; p = 0,16) ou à l’insuffisance cardiaque (14,9 % vs 10,1 %; p = 0,12). Après stratification des patients selon leur fonction ventriculaire gauche,
un faible VSI a été associé à des manifestations indésirables futures chez les patients
dont cette fonction était réduite (rapport des risques instantanés : 3,37; IC à 95
% : de 1,26 à 8,98; p = 0,015), avec des issues cliniques comparables à celles observées chez les patients
dont cette fonction était préservée. Dans le sous-groupe de patients dont la fonction
ventriculaire gauche était réduite, le faible débit était un facteur prédictif indépendant
de manifestations indésirables.
Conclusions
Le VSI peut contribuer à une meilleure caractérisation des patients présentant une
sténose aortique à gradient élevé et pourrait aider au dépistage des sujets exposés
à un risque accru à la suite d’un RVAC.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Canadian Journal of CardiologyAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery.N Engl J Med. 2010; 363: 1597-1607
- Transcatheter aortic-valve replacement for inoperable severe aortic stenosis.N Engl J Med. 2012; 366: 1696-1704
- Surgical or transcatheter aortic-valve replacement in intermediate-risk patients.N Engl J Med. 2017; 376: 1321-1331
- Transcatheter or surgical aortic-valve replacement in intermediate-risk patients.N Engl J Med. 2016; 374: 1609-1620
- Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients.N Engl J Med. 2019; 380: 1695-1705
- Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients.N Engl J Med. 2019; 380: 1706-1715
- 2017 ESC/EACTS Guidelines for the management of valvular heart disease.Eur Heart J. 2017; 38: 2739-2791
- Transcatheter aortic valve implantation for patients with severe bicuspid aortic valve stenosis.Circ Cardiovasc Interv. 2013; 6: 284-291
- Paradoxical low flow aortic valve stenosis: incidence, evaluation, and clinical significance.Curr Cardiol Rep. 2014; 16: 431
- Clinical outcomes of patients with low-flow, low-gradient, severe aortic stenosis and either preserved or reduced ejection fraction undergoing transcatheter aortic valve implantation.Eur Heart J. 2013; 34: 3437-3450
- Predictors of mortality and symptomatic outcome of patients with low-flow severe aortic stenosis undergoing transcatheter aortic valve replacement.J Am Heart Assoc. 2018; 7e007977
- Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography.Eur Heart J Cardiovasc Imaging. 2017; 18: 254-275
- Patient selection for transcatheter aortic valve implantation: patient risk profile and anatomical selection criteria.Arch Cardiovasc Dis. 2012; 105: 165-173
- Transcatheter aortic valve implantation: predictors of procedural success—the Siegburg-Bern experience.Eur Heart J. 2010; 31: 984-991
- Incidence and predictors of early and late mortality after transcatheter aortic valve implantation in 663 patients with severe aortic stenosis.Circulation. 2011; 123: 299-308
- Development and validation of a risk prediction model for in-hospital mortality after transcatheter aortic valve replacement.JAMA Cardiol. 2016; 1: 46-52
- Risk stratification of patients with aortic stenosis.Eur Heart J. 2010; 31: 416-423
- The transcatheter aortic valve implantation (TAVI) quality report: a call to arms for improving quality in Canada.Can J Cardiol. 2018; 34: 330-332
- Predictors of mortality and outcomes of therapy in low-flow severe aortic stenosis: a Placement of Aortic Transcatheter Valves (PARTNER) trial analysis.Circulation. 2013; 127: 2316-2326
- Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography.J Am Soc Echocardiogr. 2017; 30: 372-392
Article info
Publication history
Published online: August 29, 2019
Accepted:
August 21,
2019
Received:
May 31,
2019
Footnotes
See editorial by Guzzetti et al., pages 27–29 of this issue.
See page 117 for disclosure information.
Identification
Copyright
© 2019 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
ScienceDirect
Access this article on ScienceDirectLinked Article
- Importance of Flow in Risk Stratification of Aortic StenosisCanadian Journal of CardiologyVol. 36Issue 1
- PreviewOptimal risk stratification and therapeutic decision making in aortic stenosis (AS) require accurate grading of AS severity and proper assessment of the extent of cardiac damage related to AS. The peak aortic jet velocity and mean transvalvular pressure gradient are the main parameters used to grade AS severity, and severe AS is defined as a mean gradient ≥ 40 mm Hg or peak jet velocity ≥ 4 m/s. However, the main limitation of these parameters is that they are highly flow dependent and may thus underestimate AS severity in the presence of low-flow states.
- Full-Text
- Preview
