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.
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
- Burden of valvular heart diseases: a population-based study.Lancet. 2006; 368: 1005-1011
- Epidemiology of acquired valvular heart disease.Can J Cardiol. 2014; 3: 962-970
- A prospective survey of patients with valvular heart disease in Europe: the Euro Heart Survey on Valvular Heart Disease.Eur Heart J. 2003; 24: 1231-1243
- Large-scale community echocardiographic screening reveals a major burden of undiagnosed valvular heart disease in older people: the OxVALVE population cohort study.Eur Heart J. 2016; 37: 3515-3522
- 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2014; 63: 2438-2488
- 2017 ESC/EACTS guidelines for the management of valvular heart disease: the Task Force for the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS).Eur Heart J. 2017; 38: 2739-2791
- Staging classification of aortic stenosis based on the extent of cardiac damage.Eur Heart J. 2017; 38: 3351-3358
- Association of structural and functional cardiac changes with transcatheter aortic valve replacement outcomes in patients with aortic stenosis.JAMA Cardiol. 2019; 4: 215-222
- Staging cardiac damage in patients with asymptomatic aortic valve stenosis.J Am Coll Cardiol. 2019; 7: 550-563
- Staging cardiac damage in patients with symptomatic aortic valve stenosis.J Am Coll Cardiol. 2019; 7: 538-549
- 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; 3: 372-392
- Recommendations for non invasive evaluation of native valvular regurgitation: a report from the American Society of Echocardiography developed in collaboration with the Society for Cardiovascular Magnetic Resonance.J Am Soc Echocardiogr. 2017; 3: 303-371
- Combined aortic stenosis and regurgitation: double the trouble.Heart (British Cardiac Society). 2019; 105: 1515-1522
- 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines.J Am Coll Cardiol. 2017; 7: 252-289
- Incremental value of left ventricular global longitudinal strain in a newly proposed staging classification based on cardiac damage in patients with severe aortic stenosis.Eur Heart J Cardiovasc Imaging. 2020; 21: 1248-1258
- Invasive hemodynamic staging classification of cardiac damage in patients with aortic stenosis undergoing valve replacement.Can J Cardiol. 2020; 36: 1667-1674
- Effect of transcatheter aortic valve replacement on right ventricular-pulmonary artery coupling.JACC Cardiovasc Interv. 2019; 12: 2145-2154
- Impact of pulmonary hypertension hemodynamic status on long-term outcome after transcatheter aortic valve replacement.JACC Cardiovasc Interv. 2019; 12: 2155-2168
- Echocardiographic predictors of outcomes in adults with aortic stenosis.Heart. 2016; 1: 934-942
- Assessment of subclinical left ventricular dysfunction in aortic stenosis.JACC Cardiovascular imaging. 2019; 1: 163-171
- Reduced left ventricular ejection fraction in patients with aortic stenosis.J Am Coll Cardiol. 2018; 71: 1313-1321
- Distribution and prognostic significance of left ventricular global longitudinal strain in asymptomatic significant aortic stenosis: an individual participant data meta-analysis.JACC Cardiovasc Imaging. 2019; 1: 84-92
- Survival benefit of aortic valve replacement in patients with severe aortic regurgitation and pulmonary hypertension.Ann Thorac Surg. 2009; 8: 752-756
- Decision making in asymptomatic aortic regurgitation in the era of guidelines: incremental values of resting and exercise cardiac dysfunction.Circulation Cardiovasc Imaging. 2014; 7: 352-362
- Long-term outcomes in patients with aortic regurgitation and preserved left ventricular ejection fraction.J Am Coll Cardiol. 2016; 68: 2144-2153
- Outcomes in chronic hemodynamically significant aortic regurgitation and limitations of current guidelines.J Am Coll Cardiol. 2019; 73: 1741-1752
- Early detection of subclinical myocardial damage in chronic aortic regurgitation and strategies for timely treatment of asymptomatic patients.Circulation. 2018; 13: 184-196
- Incremental prognostic utility of left ventricular global longitudinal strain in asymptomatic patients with significant chronic aortic regurgitation and preserved left ventricular ejection fraction.JACC Cardiovasc Imaging. 2018; 1: 673-682
- Long-term outcomes after aortic valve surgery in patients with asymptomatic chronic aortic regurgitation and preserved LVEF: impact of baseline and follow-up global longitudinal strain.JACC Cardiovasc Imaging. 2020; 13: 12-21
- Outcome of combined stenotic and regurgitant aortic valve disease.J Am Coll Cardiol. 2013; 61: 1489-1495
- Mixed aortic valve disease: midterm outcome and predictors of adverse events.Eur Heart J. 2016; 37: 2671-2678
- Outcomes of asymptomatic adults with combined aortic stenosis and regurgitation.J Am Soc Echocardiogr. 2014; 2: 829-837
- Outcomes in moderate mixed aortic valve disease: is it time for a paradigm shift?.J Am Coll Cardio. 2016; 67: 2321-2329
- Natural history, diagnostic approaches, and therapeutic strategies for patients with asymptomatic severe aortic stenosis.J Am Coll Cardiol. 2016; 67: 2263-2288
- Early surgery or conservative care for asymptomatic aortic stenosis.N Engl J Med. 2020; 382: 111-119
- Aortic stenosis and cardiac amyloidosis: JACC review topic of the week.J Am Coll Cardiol. 2019; 74: 2638-2651
- Cardiac damage staging in aortic stenosis: a perspective from the cardiac catheterization laboratory.Can J Cardiol. 2020; 36: 1583-1586
- 2019 Canadian Cardiovascular Society position statement for aortic valve implantation.Can J Cardiol. 2019; 35: 1437-1448
- Transcatheter aortic valve replacement in pure native aortic valve regurgitation.J Am Coll Cardiol. 2017; 70: 2752-2763
- The incidence and prognostic implications of worsening right ventricular function after surgical or transcatheter aortic valve replacement: insights from PARTNER IIA.Eur Heart J. 2018; 39: 2659-2667
- Echocardiographic results of transcatheter versus surgical aortic valve replacement in low-risk patients: The PARTNER 3 trial.Circulation. 2020; 141: 1527-1537
- Risk stratification in patients with aortic stenosis: pay more attention to the right-side unit!.JACC Cardiovasc Interv. 2019; 12: 2169-2172
- Midwall fibrosis and 5-year outcome in moderate and severe aortic stenosis.J Am Coll Cardiol. 2017; 69: 1755-1756
- Midwall fibrosis is an independent predictor of mortality in patients with aortic stenosis.J Am Coll Cardiol. 2011; 58: 1271-1279
- Relation of N-terminal pro B-type natriuretic peptide to progression of aortic valve disease.Eur Heart J. 2005;
- Natriuretic peptides for risk stratification of patients with valvular aortic stenosis.Circ Heart Fail. 2015; 8: 373-380
- B-Type natriuretic peptide clinical activation in aortic stenosis: Impact on long-term survival.J Am Coll Cardiol. 2014; 63: 2016-2025
- Prognostic utility of novel biomarkers of cardiovascular stress in patients with aortic stenosis undergoing valve replacement.Heart. 2015; 101: 1382-1388
- High-sensitivity troponin I concentrations are a marker of an advanced hypertrophic response and adverse outcomes in patients with aortic stenosis.Eur Heart J. 2014; 35: 2312-2321
- A clinical risk score of myocardial fibrosis predicts adverse outcomes in aortic stenosis.Eur Heart J. 2016; 3: 713-723
- Myocardial fibrosis and cardiac decompensation in aortic stenosis.JACC Cardiovasc Imaging. 2017; 10: 1320-1333
- B-Type natriuretic peptide and high-sensitivity cardiac troponin for risk stratification in low-flow, low-gradient aortic stenosis.JACC Cardiovasc Imaging. 2018; 1: 939-947
- Relationship between B-type natriuretic peptide and invasive haemodynamics in patients with severe aortic valve stenosis.ESC Heart Fail. 2020; 7: 577-587
- Low and elevated B-type natriuretic peptide levels are associated with increased mortality in patients with preserved ejection fraction undergoing transcatheter aortic valve replacement: an analysis of the PARTNER II trial and registry.Eur Heart J. 2020; 4: 958-969
- Increased levels of cardiac troponin I in subjects with extremely low B-type natriuretic peptide levels.Sci Rep. 2018; 8: 5120
- Aortic valve surgery and survival in patients with moderate or severe aortic stenosis and left ventricular dysfunction.Eur Heart J. 2016; 37: 2276-2286
- Prognostic implications of moderate aortic stenosis in patients with left ventricular systolic dysfunction.J Am Coll Cardiol. 2017; 69: 2383-2392
- Aortic stenosis: the emperor’s new clothes.J Am Coll Cardiol. 2019; 74: 1864-1867
Article info
Publication history
Published online: January 31, 2021
Accepted:
January 22,
2021
Received:
December 1,
2020
Footnotes
See page 1013 for disclosure information.
Identification
Copyright
© 2021 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
