Asymptomatic Severe Aortic Stenosis in the Elderly

Zilberszac, Robert; Gabriel, Harald; Schemper, M.; Laufer, Günther; Maurer, Gerald; Rosenhek, Raphaël

doi:10.1016/j.jcmg.2016.05.015

Cited by 67 publications

(28 citation statements)

References 26 publications

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“…A recent study of 103 asymptomatic patients with severe AS aged >70 years reported that a Vmax ≥5 m/s was predictive of AVR or death. 24 These studies have undeniably validated Vmax as an outcome predictor in AS. However, the relationship between Vmax and survival per se has not been specifically investigated.…”

Section: Discussionmentioning

confidence: 99%

Risk Stratification of Severe Aortic Stenosis With Preserved Left Ventricular Ejection Fraction Using Peak Aortic Jet Velocity

Bohbot

Ruşinaru

Delpierre

et al. 2017

Circ: Cardiovascular Imaging

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Background— Current guidelines consider aortic valve replacement reasonable in asymptomatic patients with very severe aortic stenosis (AS); however, the definition of very severe AS based on peak aortic jet velocity (Vmax) remains unclear with a 5-m/s cutoff in US guidelines and 5.5 m/s in European guidelines. Because ≈20% of patients with severe AS and preserved left ventricular ejection fraction have Vmax in this range, we aimed to assess the relationship between Vmax and mortality and determine the best threshold to define very severe AS. Methods and Results— A total of 1140 patients with severe AS (aortic valve area ≤1 cm 2 , Vmax ≥4 m/s) and preserved left ventricular ejection fraction were included. The population was divided into 4 groups according to Vmax (4–4.49, 4.5–4.99, 5–5.49, and ≥5.5 m/s). After adjustment for covariates (including surgery), there was no difference in all-cause mortality between Vmax 4 to 4.49 m/s and Vmax 4.5 to 4.99 m/s ( P =0.64). Both Vmax 5 to 5.49 m/s and Vmax ≥5.5 m/s exhibited significant excess mortality compared with Vmax 4 to 4.49 m/s (adjusted hazard ratio=1.34 [1.18–1.52]; P <0.001, and 1.28 [1.16–1.41]; P <0.001, respectively). Mortality risk was similar for Vmax 5 to 5.49 m/s and Vmax ≥5.5 m/s ( P =0.93). Compared with Vmax <5 m/s, patients with Vmax ≥5 m/s had greater mortality risk (adjusted hazard ratio=1.86 [1.55–2.54]; P <0.001), even in the subgroup of asymptomatic even in the subgroup of asymptomatic patients (adjusted hazard ratio=2.08 [1.25-3.46]; P =0.005). Conclusions— Our results demonstrate the strong relationship between Vmax and mortality in patients with severe AS and preserved left ventricular ejection fraction irrespective of symptoms. Vmax ≥5 m/s at the time of AS diagnosis identifies patients with very severe AS at high risk of death.

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Section: Discussionmentioning

confidence: 99%

Risk Stratification of Severe Aortic Stenosis With Preserved Left Ventricular Ejection Fraction Using Peak Aortic Jet Velocity

Bohbot

Ruşinaru

Delpierre

et al. 2017

Circ: Cardiovascular Imaging

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“…21 Initial symptoms experienced by patients with AS, who are usually elderly, are often subtle, and many patients fail to acknowledge or report their symptoms until overt heart failure presents. 22 Early AVR is debated in asymptomatic patients, and the optimal timing for AVR remains controversial because of the lack of prospective studies on the determinants of AS progression, studies on risk stratification, and patient management. 23 Because longitudinal function at rest is related to patients' prognosis, we sought to investigate the additional value of longitudinal function at exercise in patients with asymptomatic AS.…”

mentioning

confidence: 99%

The Association Between Longitudinal Strain at Rest and Stress and Outcome in Asymptomatic Patients With Moderate and Severe Aortic Stenosis

Levy-Neuman

Meledin

Gandelman

et al. 2019

Journal of the American Society of Echocardiography

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Background: Calcific aortic stenosis (AS) is a progressive disease, and once moderate AS is present, the likelihood of symptom onset within 5 years is significant. The aim of this study was to determine the incremental value of global longitudinal strain (GLS) and basal longitudinal strain (BLS) at rest and during exercise on outcomes among asymptomatic patients' with moderate and severe AS. Methods: Seventy-five patients with isolated, asymptomatic AS and preserved left ventricular function were retrospectively enrolled and underwent symptom-limited exercise echocardiography. Clinical and echocardiographic data, including GLS and BLS at rest and during exercise, were assessed. Occurrence of ASrelated cardiovascular events was recorded. Results: The mean age was 71 6 10 years, and 63% were men. The mean aortic valve gradient was 30 6 11 mm Hg, and the mean aortic valve area was 0.98 6 0.21 cm 2. Resting GLS and BLS were À16.5 6 4% and À16.9 6 3.6%, respectively. Exercise stress test results were positive in 27 patients (36%). Mean exercise GLS was À17.8 6 3.5%, and mean exercise BLS was À17.9 6 4%. During mean follow-up of 34.5 6 3.5 months, cardiovascular events were observed in 45 patients. In multivariate analysis, aortic valve mean gradient (HR, 1.073; 95% CI, 1.032-1.115; P < .001) and peak exercise BLS (HR, 1.177; 95% CI, 1.07-1.295; P = .001) were associated with cardiac events during follow-up. Conclusions: Reduced exercise BLS is associated with future cardiovascular events in patients' with asymptomatic AS, independently of clinical factors and conventional echocardiographic parameters. Detection of postexercise myocardial dysfunction in patients with asymptomatic AS with preserved left ventricular function can aid in risk assessment of these patients.

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“…En nuestra población se considera EA severa cuando, Las guías sobre manejo de la enfermedad valvular de la AHA/ACC (2) recomiendan como indicación clase IIA la sustitución valvular aórtica en la EA severa asintomática con FEVI conservada y VMáx ³5 m/s, en tanto la ESC la aconseja con VMáx ³5,5 m/s (1) . En un trabajo reciente, Zilberszac (15) realiza un seguimiento de 103 pacientes mayores de 70 años con EA severa asintomática. Define la EA muy severa con una VMáx ³5 m/s en base a que es un punto de corte que predice la evolución en forma independiente.…”

Section: Discussionunclassified

Reclasificación de la severidad de la estenosis aórtica con la utilización del enfoque paraesternal derecho con transductor ciego

2017

Rev. Urug. Cardiol.

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La severidad de la estenosis aórtica (EA) es uno de los pilares que decide la sustitución valvular. El ecocardiograma Doppler (ED) es de elección para el diagnóstico y cuantificación mediante la determinación de la velocidad máxima (VMáx), gradiente medio (GM) y área valvular (AV). VMáx y GM se obtienen desde múltiples enfoques, pero la utilización del enfoque paraesternal derecho (PED) es poco frecuente. Objetivo: determinar la magnitud de la reclasificación de la EA con la utilización del enfoque PED con transductor ciego. Método: se estudian prospectivamente pacientes con EA moderada o severa por ED desde cualquier enfoque. Se considera EA moderada: VMáx 3 a 3,9 m/s, GM 20 a 39 mmHg o AV 1,1 a 1,5 cm 2. EA severa: VMáx ³4 m/s, GM ³40 mmHg o AV £1 cm 2. Criterios de exclusión: fracción de eyección de ventrículo izquierdo (FEVI) <50%, insuficiencia valvular aórtica o mitral ³ moderada, hemoglobina (Hb) <11 g/dl. Se utilizan enfoques apical (ÁPEX), PED y subxifoideo con transductores convencional y ciego. Resultado: se incluyen 100 pacientes de 74,0 ±12 años, sexo femenino 49%, FEVI 69,1±8,4%. Por ÁPEX EA severa 56% y no severa 44%. Enfoque con gradiente más alto: ÁPEX 33/100, PED 48/100, más de un enfoque 19/100; las EA moderadas por ÁPEX son severas por PED: 18/33 (54,6%, IC 95% 36,4-71,9); leves por ÁPEX son severas por PED: 3/11 (27,3% IC 95% 6,0-61,0). PED reclasifica como severas 21 de las 44 consideradas moderadas o leves por ÁPEX (47,7% IC 95% 32,5-63,3). Conclusión: el enfoque PED obtiene los valores de gradiente más altos en 48% de los casos. En EA no severa por ÁPEX, el PED reclasifica como severa una de cada dos.

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Asymptomatic Severe Aortic Stenosis in the Elderly

Cited by 67 publications

References 26 publications

Risk Stratification of Severe Aortic Stenosis With Preserved Left Ventricular Ejection Fraction Using Peak Aortic Jet Velocity

Risk Stratification of Severe Aortic Stenosis With Preserved Left Ventricular Ejection Fraction Using Peak Aortic Jet Velocity

The Association Between Longitudinal Strain at Rest and Stress and Outcome in Asymptomatic Patients With Moderate and Severe Aortic Stenosis

Reclasificación de la severidad de la estenosis aórtica con la utilización del enfoque paraesternal derecho con transductor ciego

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