Impact of Classic and Paradoxical Low Flow on Survival After Aortic Valve Replacement for Severe Aortic Stenosis

Clavel, Marie‐Annick; Berthelot-Richer, Maxime; Ven, Florent Le; Capoulade, Romain; Dahou, Abdellaziz; Dumesnil, Jean G.; Mathieu, Patrick; Pîbarot, Philippe

doi:10.1016/j.jacc.2014.11.047

Cited by 90 publications

(62 citation statements)

References 26 publications

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“…This phenotype is often misleading for clinicians because establishing the diagnosis can be challenging and the prognosis falsely reassuring given a heart that is not dilated or hypokinetic (to the contrary, the LV often appears hyperdynamic). However, studies have convincingly shown, and our data reaffirm, that paradoxical low‐gradient AS constitutes a particularly high‐risk group with operative risk of 6% to 33% and medically treated survival <50% at 3 years 27, 28, 29, 30. Patients with paradoxical low‐gradient AS are particularly vulnerable to the deleterious effects of patient‐prosthesis mismatch and, accordingly, may be good candidates for TAVR.…”

Section: Discussionsupporting

confidence: 74%

Risk Prediction in Aortic Valve Replacement: Incremental Value of the Preoperative Echocardiogram

Tan

Flynn

Chen‐Tournoux

et al. 2015

JAHA

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BackgroundRisk prediction is a critical step in patient selection for aortic valve replacement (AVR), yet existing risk scores incorporate very few echocardiographic parameters. We sought to evaluate the incremental predictive value of a complete echocardiogram to identify high‐risk surgical candidates before AVR.Methods and ResultsA cohort of patients with severe aortic stenosis undergoing surgical AVR with or without coronary bypass was assembled at 2 tertiary centers. Preoperative echocardiograms were reviewed by independent observers to quantify chamber size/function and valve function. Patient databases were queried to extract clinical data. The cohort consisted of 432 patients with a mean age of 73.5 years and 38.7% females. Multivariable logistic regression revealed 3 echocardiographic predictors of in‐hospital mortality or major morbidity: E/e’ ratio reflective of elevated left ventricular (LV) filling pressure; myocardial performance index reflective of right ventricular (RV) dysfunction; and small LV end‐diastolic cavity size. Addition of these echocardiographic parameters to the STS risk score led to an integrated discrimination improvement of 4.1% (P<0.0001). After a median follow‐up of 2 years, Cox regression revealed 5 echocardiographic predictors of all‐cause mortality: small LV end‐diastolic cavity size; LV mass index; mitral regurgitation grade; right atrial area index; and mean aortic gradient <40 mm Hg.ConclusionsEchocardiographic measures of LV diastolic dysfunction and RV performance add incremental value to the STS risk score and should be integrated in prediction when evaluating the risk of AVR. In addition, findings of small hypertrophied LV cavities and/or low mean aortic gradients confer a higher risk of 2‐year mortality.

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Section: Discussionsupporting

confidence: 74%

Risk Prediction in Aortic Valve Replacement: Incremental Value of the Preoperative Echocardiogram

Tan

Flynn

Chen‐Tournoux

et al. 2015

JAHA

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“…Delay of aortic valve replacement in these patients worsens their outcome32; however, the group's operative risk is increased 33…”

Section: Discussionmentioning

confidence: 99%

Myocardial Oxygen Consumption and Efficiency in Aortic Valve Stenosis Patients With and Without Heart Failure

Hansson

Sørensen

Harms

et al. 2017

JAHA

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BackgroundMyocardial oxygen consumption (MVO2) and its coupling to contractile work are fundamentals of cardiac function and may be involved causally in the transition from compensated left ventricular hypertrophy to failure. Nevertheless, these processes have not been studied previously in patients with aortic valve stenosis (AS).Methods and ResultsParticipants underwent 11C‐acetate positron emission tomography, cardiovascular magnetic resonance, and echocardiography to measure MVO2 and myocardial external efficiency (MEE) defined as the ratio of left ventricular stroke work and the energy equivalent of MVO2. We studied 10 healthy controls (group A), 37 asymptomatic AS patients with left ventricular ejection fraction ≥50% (group B), 12 symptomatic AS patients with left ventricular ejection fraction ≥50% (group C), and 9 symptomatic AS patients with left ventricular ejection fraction <50% (group D). MVO2 did not differ among groups A, B, C, and D (0.105±0.02, 0.117±0.024, 0.129±0.032, and 0.104±0.026 mL/min per gram, respectively; P=0.07), whereas MEE was reduced in group D (21.0±1.6%, 22.3±3.3%, 22.1±4.2%, and 17.3±4.7%, respectively; P<0.05). Similarly, patients with global longitudinal strain greater than −12% and paradoxical low‐flow, low‐gradient AS had impaired MEE (P<0.05 versus controls). The ability to discriminate between symptomatic and asymptomatic patients was superior for global longitudinal strain compared with MVO2 and MEE (area under the curve 0.98, 0.48, and 0.61, respectively; P<0.05).ConclusionsAS patients display a persistent ability to maintain normal MVO2 and MEE (ie, the ability to convert energy into stroke work); however, patients with left ventricular ejection fraction <50%; global longitudinal strain greater than −12%; or paradoxical low‐flow, low‐gradient AS demonstrate reduced MEE. These findings suggest that mitochondrial uncoupling contributes to the dismal prognosis in patients with reduced contractile function or paradoxical low‐flow, low‐gradient AS.

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“…6 Severity of coexisting coronary artery disease was associated with impaired clinical outcomes at 1 year after TAVR in 445 patients with severe AS (mean age, 82.5 years; 56% female). 7 Severe AS and left ventricular ejection fraction of <50% with or without aortic valve replacement, 8,9 low-flow, low-gradient AS with reduced stroke volume index, [10][11][12][13] and reduced global longitudinal strain by speckle-tracking echocardiography 14 have increased risk of mortality after sAVR or TAVR in patients with severe AS. Midwall myocardial fibrosis that can be detected by late gadolinium enhancement, 15 and prosthesispatient mismatch 16,17 have also been reported as prognosticators in patients with severe AS after sAVR or TAVR.…”

Section: See Article By Treibel Et Almentioning

confidence: 99%

“…[6][7][8][9][10][11][12][13][14][15][16][17] The coexistence of wtATTR and severe AS may cause severe hypertrophy and left ventricular functional impairment, which can be misdiagnosed as low-flow, low-gradient severe AS. [10][11][12][13] Recent studies have suggested that patients with wtATTR are characterized by lower left ventricular ejection fraction, stroke volume index, left ventricular basal, and midradial strains compared with age and wall thickness matched mutant ATTR patients. 18 These finding may be helpful in distinguishing wtATTR cardiac amyloidosis from patients with other causes of left ventricular hypertrophy.…”

Section: See Article By Treibel Et Almentioning

confidence: 99%

Prognostic Significance of Occult Transthyretin Cardiac Amyloidosis in Patients With Severe Aortic Stenosis Undergoing Surgical Aortic Valve Replacement

Koyama

2016

Circ: Cardiovascular Imaging

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Impact of Classic and Paradoxical Low Flow on Survival After Aortic Valve Replacement for Severe Aortic Stenosis

Cited by 90 publications

References 26 publications

Risk Prediction in Aortic Valve Replacement: Incremental Value of the Preoperative Echocardiogram

Risk Prediction in Aortic Valve Replacement: Incremental Value of the Preoperative Echocardiogram

Myocardial Oxygen Consumption and Efficiency in Aortic Valve Stenosis Patients With and Without Heart Failure

Prognostic Significance of Occult Transthyretin Cardiac Amyloidosis in Patients With Severe Aortic Stenosis Undergoing Surgical Aortic Valve Replacement

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