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Canadian Journal of Cardiology

The Role of Extravalvular Cardiac Damage Staging in Aortic Valve Disease Management

  • Lionel Tastet
    Affiliations
    Institut universitaire de cardiologie et de pneumologie de Québec—Université Laval, Québec City, Québec, Canada
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  • Philippe Généreux
    Affiliations
    Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA

    Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA

    Hôpital du Sacré-Cœur de Montréal, Montréal, Québec, Canada
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  • Jérémy Bernard
    Affiliations
    Institut universitaire de cardiologie et de pneumologie de Québec—Université Laval, Québec City, Québec, Canada
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  • Philippe Pibarot
    Correspondence
    Corresponding author: Dr Philippe Pibarot, Institut Universitaire de Cardiologie et de Pneumologie de Québec—Université Laval 2725 Chemin Sainte-Foy, Québec City, Québec G1V 4G5, Canada. Tel.: +1-418-656-8711 ext 5938; fax: +1-418-656-4715.
    Affiliations
    Institut universitaire de cardiologie et de pneumologie de Québec—Université Laval, Québec City, Québec, Canada
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Published:January 31, 2021DOI:https://doi.org/10.1016/j.cjca.2021.01.020

      Abstract

      Current management of patients with aortic valve disease, including aortic valve stenosis (AS), aortic valve regurgitation (AR), and mixed aortic valve disease (MAVD), remains challenging. American and European guideline recommendations regarding the timing of intervention are mainly based on the assessment of disease severity (ie, grading), presence of symptoms related to aortic valve disease, left ventricular systolic dysfunction, or LV enlargement. Furthermore, the decision regarding the type of intervention (ie, surgical vs transcatheter) is primarily based on risk assessment from surgical risk scores. There is, however, less emphasis on the importance of the assessment of anatomic and functional cardiac repercussions of aortic valve disease to guide the clinical management of these patients. Recently, a novel approach has been proposed to improve the management of aortic valve disease with 2 main components for risk stratification of the disease: 1) grading the severity of aortic valve disease, and 2) staging the extent of extravalvular cardiac damage associated with aortic valve disease with the use of echocardiography. To date, this novel approach of extravalvular cardiac damage staging was proposed and validated only in the context of AS but could be extended to other valvular heart diseases, including AR and MAVD. Further studies are also needed to test the incremental value of additional imaging parameters (eg, myocardial fibrosis by magnetic resonance) as well as blood biomarkers (eg, natriuretic peptide, cardiac troponin, and others) to the existing cardiac damage staging schemes.

      Résumé

      La prise en charge courante des patients atteints d’une valvulopathie aortique, comprenant une sténose aortique, une insuffisance valvulaire aortique et une valvulopathie aortique mixte, demeure difficile. Les recommandations formulées dans les lignes directrices américaines et européennes concernant le moment opportun pour l’intervention reposent essentiellement sur l’évaluation de la gravité de la maladie (c.-à-d., classification de la sévérité) et la présence de symptômes liés à la valvulopathie aortique, de l’apparition d'une dysfonction systolique ventriculaire gauche ou d’une hypertrophie ventriculaire gauche. Par ailleurs, la décision quant au type d’intervention (c.-à-d., chirurgie ou par voie transcathéter) est basée principalement sur l’évaluation des risques associés, et ce à l’aide des scores de risque chirurgical. Toutefois, l’évaluation des répercussions cardiaques anatomiques et fonctionnelles de la valvulopathie aortique pour guider la prise en charge clinique de ces patients occupe une place moins importante. Récemment, une nouvelle approche a été proposée pour améliorer la prise en charge des valvulopathies aortiques par deux grands éléments de stratification du risque de la maladie : 1) déterminer la sévérité de la valvulopathie aortique; 2) classer l’étendue des lésions cardiaques extravalvulaires associées à la valvulopathie aortique au moyen de l’échocardiographie. À ce jour, cette nouvelle approche de classification des lésions cardiaques extravalvulaires a été proposée et validée seulement dans le contexte de la sténose aortique, mais pourrait être élargie à d’autres cardiopathies valvulaires, dont l'insuffisance aortique et la valvulopathie aortique mixte. D’autres études sont nécessaires afin d’évaluer si l’ajout de paramètres d’imagerie (p. ex. fibrose myocardique par résonance magnétique) et de biomarqueurs sanguins (p. ex. peptide natriurétique, troponine cardiaque et autres) aux schémas existants de classification des lésions cardiaques extravalvulaires confère une valeur additionnelle à la stratification du risque.
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