Haemodynamic and metabolic phenotyping of patients with aortic stenosis and preserved ejection fraction: A specific phenotype of heart failure with preserved ejection fraction?

Abstract

BackgroundDegenerative aortic valve stenosis with preserved left ventricular ejection fraction (ASpEF) and heart failure with preserved left ventricular ejection fraction (HFpEF) display intriguing similarities. We designed this study to provide a non‐invasive, comparative analysis of ASpEF versus HFpEF at rest and during exercise.Methods and resultsWe prospectively enrolled 148 patients with HFpEF and 150 patients with degenerative moderate‐to‐severe ASpEF, together with 66 age‐ and sex‐matched healthy controls. All subjects received a comprehensive evaluation at rest and 351/364 (96%) performed a combined cardiopulmonary‐exercise stress echocardiography test. Patients with ASpEF eligible for transcatheter aortic valve replacement (n=125) also performed cardiac computed tomography (CT). HFpEF and ASpEF patients showed similar demographic distribution and biohumoral profiles. Most patients with ASpEF (134/150, 89%) had severe high‐gradient aortic stenosis; 6/150 (4%) had normal‐flow, low‐gradient ASpEF, while 10/150 (7%) had low‐flow, low‐gradient ASpEF. Both patient groups displayed significantly lower peak oxygen consumption (VO2), peak cardiac output, and peak arteriovenous oxygen difference compared to controls (all p<0.01). ASpEF patients showed several extravalvular abnormalities at rest and during exercise, similar to HFpEF (all p<0.01 vs controls). Epicardial adipose tissue (EAT) thickness was significantly greater in ASpEF than HFpEF and was inversely correlated with peak VO2 in all groups. In ASpEF, EAT was directly related to echocardiography‐derived disease severity and CT‐derived aortic valve calcium burden.ConclusionsFunctional capacity is similarly impaired in ASpEF and HFpEF due to both peripheral and central components. Further investigation is warranted to determine whether extravalvular alterations may affect disease progression and prognosis in ASpEF even after valve intervention, which could support the concept of ASpEF as a specific subphenotype of HFpEF.This article is protected by copyright. All rights reserved.

Aortic stenosis and heart failure with preserved ejection fraction: A shared phenotypic puzzle

“…7,8 The role of EAT appears to be related to inflammation, mechanical effects, and its proximity to the heart and major blood vessels. In the study of De Biase et al, 1 greater EAT thickness showed an inverse correlation with peak VO 2 at cardiopulmonary exercise testing in both HFpEF and AS. When analysing the AS cohort, EAT thickness was directly related to indices of valve disease severity, including peak transvalvular velocity, mean transvalvular pressure gradient (at rest and peak exercise), and aortic valve calcium score and volume.…”

“…In this issue of the Journal, De Biase et al 1 compare the haemodynamic and metabolic characteristics of patients with degenerative severe AS versus patients with HFpEF. Patients with AS (n = 150) were characterized by isolated aortic valve disease with high transvalvular gradients and preserved left ventricular (LV) ejection fraction, thereby excluding those with low-flow low-gradient AS with reduced LV function, or concomitant mitral valve disease.…”

mPAP/CO Slope and Oxygen Uptake Add Prognostic Value in Aortic Stenosis

“…In addition, CPETecho can reveal noncardiac symptoms and limitations. 34 For instance, a low peak Vo 2 in the absence of ex-PHT could be caused by a diminished breathing reserve or a submaximal test, indicated by a low respiratory exchange ratio. 14,35 Patients with AS denying symptoms in daily life could be considered truly asymptomatic, particularly when they have a normal peak Vo 2 or low mPAP/CO slope.…”

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“…Functional capacity was similarly impaired in AVS and HFpEF patients due to both peripheral and central components. Epicardial adipose tissue thickness was inversely correlated with peak oxygen consumption in all subjects, was greater and directly related to echocardiography‐derived disease severity and computed tomography‐derived aortic valve calcium burden in patients with AVS and preserved EF 15 …”