Abstract
Background
An echocardiographic 5-stage classification of cardiac damage in aortic stenosis (AS)
has been shown to provide prognostic information. We aimed to create an analogous
classification based on invasive hemodynamics.
Methods
We studied 421 patients (age 75 ± 10 years, 59% men) with severe AS with complete
invasive hemodynamics obtained before aortic valve replacement (AVR). Cardiac damage
stages were defined as follows: stage 0, absence of any of the following criteria;
stage 1, left-ventricular end-diastolic pressure >15 mm Hg; stage 2, mean pulmonary
artery wedge pressure > 15 mm Hg; stage 3, pulmonary vascular resistance > 3 Wood
units and/or systolic pulmonary artery pressure > 60 mm Hg; stage 4, mean right atrial
pressure >15 mm Hg. Patients were hierarchically classified in a given stage (worst
stage) if the criterion was met for that stage.
Results
Sixty-seven (16%) patients were classified as stage 0, 113 (27%) as stage 1, 151 (36%)
as stage 2, 73 (17%) as stage 3, and 17 (4%) as stage 4. After a median (interquartile
range) follow-up of 3.8 (2.7 to 5.2) years after AVR, mortality was highest in stage
4 (hazard ratio; 95% confidence interval: 6.17 (1.74-21.89) vs stage 0; P = 0.005 and stage 3 patients (hazard ratio; 95% confidence interval: 4.17 (1.39-12.49)
vs stage 0; P = 0.01,whereas mortality did not differ between patients in stages 0 to 2.
Conclusions
A staging system of cardiac damage based on invasive hemodynamic parameters in patients
with severe AS undergoing AVR predicts mortality. Pulmonary vascular disease and high
right-atrial pressure are the major drivers of mortality.
Résumé
Contexte
Il a été démontré que la classification échocardiographique des lésions cardiaques
en cinq stades présente un intérêt pronostique dans les cas de sténose aortique (SA).
Notre objectif était de créer une classification analogue fondée sur des paramètres
hémodynamiques mesurés par une méthode invasive.
Méthodologie
Nous avons mené une étude portant sur 421 patients (âgés de 75 ± 10 ans, 59 % de sexe
masculin) présentant une SA grave qui ont passé une évaluation hémodynamique invasive
complète avant de subir un remplacement valvulaire aortique (RVA). Les stades des
lésions cardiaques étaient définis comme suit : stade 0, absence de tout critère parmi
ceux des stades 1 à 4; stade 1, pression télédiastolique ventriculaire gauche supérieure
à 15 mmHg; stade 2, pression capillaire pulmonaire bloquée moyenne supérieure à 15
mmHg; stade 3, résistance vasculaire pulmonaire supérieure à 3 unités Wood et/ou pression
artérielle pulmonaire systolique supérieure à 60 mmHg; stade 4, pression auriculaire
droite moyenne supérieure à 15 mmHg. Les patients ont été l’objet d’une classification
hiérarchique à un stade donné (le pire stade) s’ils répondaient au critère de ce stade.
Résultats
Nous avons recensé 67 patients (16 %) au stade 0, 113 (27 %) au stade 1, 151 (36 %)
au stade 2, 73 (17 %) au stade 3, et 17 (4 %) au stade 4. À l’issue d’un suivi médian
de 3,8 ans (intervalle interquartile : 2,7-5,2 ans) après le RVA, la mortalité était
plus élevée au stade 4 (rapport des risques instantanés : 6,17, intervalle de confiance
à 95 % : 1,74-21,89) comparativement au stade 0 (p = 0,005); il en était de même au stade 3 (rapport des risques instantanés : 4,17,
intervalle de confiance à 95 % : 1,39-12,49) comparativement au stade 0 (p = 0,01). Par ailleurs, aucune différence n’a été notée au chapitre de la mortalité
aux stades 0 à 2.
Conclusions
Un système de stadification des lésions cardiaques fondé sur des paramètres hémodynamiques
mesurés par une méthode invasive permet de prédire la mortalité chez les patients
présentant une SA grave qui doivent subir un RVA. Les maladies vasculaires pulmonaires
et une pression auriculaire droite élevée sont les principaux facteurs de mortalité.
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Article info
Publication history
Published online: February 07, 2020
Accepted:
February 4,
2020
Received:
December 5,
2019
Footnotes
See editorial by Tastet et al., pages 1583—1586 of this issue.
See page 1673 for disclosure information.
Identification
Copyright
© 2020 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
ScienceDirect
Access this article on ScienceDirectLinked Article
- Cardiac Damage Staging in Aortic Stenosis: A Perspective From the Cardiac Catheterization LaboratoryCanadian Journal of CardiologyVol. 36Issue 10
- PreviewCalcific aortic valve stenosis (AS) is a prevalent and serious cardiovascular disease that afflicts approximately 2% of elderly patients in high-income countries, and the burden of the disease is expected to increase in the next decades with the aging population.1 Aortic valve replacement (AVR), either surgical (SAVR) or transcatheter (TAVR), remains, to date, the only therapeutic option to improve the survival of patients with symptomatic severe AS. In the practice guidelines,2-5 the indication for AVR is essentially based on the presence of: (1) severe AS and (2) symptoms and/or left ventricular (LV) systolic dysfunction defined by LV ejection fraction (LVEF) < 50%.
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