Outcome of 622 Adults With Asymptomatic, Hemodynamically Significant Aortic Stenosis During Prolonged Follow-Up

Pellikka, Patricia A.; Sarano, Maurice E.; Nishimura, Rick A.; Malouf, Joseph F.; Bailey, Kent R.; Scott, Christopher G.; Barnes, Marion E.; Tajik, A. Jamil

doi:10.1161/circulationaha.104.495903

Cited by 740 publications

(396 citation statements)

References 19 publications

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“…In this study,25 2‐year event‐free survival was 30% for patients with Vmax >4.4 m/s versus 60% for patients with Vmax <4.4 m/s. Among 622 asymptomatic patients with AS and Vmax ≥4 m/s, a Vmax ≥4.5 m/s was associated with an ≈50% increased risk of cardiac events (death or AVR)26 in a report on 116 asymptomatic patients with severe AS, a Vmax ≥5.5 m/s was associated with almost 90% increase in the risk of events (death or AVR) 27. These studies undeniably validated Vmax as an outcome marker in AS, but the cutoff for identifying patients in whom the severity of the valvular obstacle is critical remains unclear, especially for patients with no or minimal symptoms, as reflected by the different criteria used to define “very severe AS” proposed by US and European guidelines 1, 2.…”

Section: Discussionmentioning

confidence: 97%

Impact of Mean Transaortic Pressure Gradient on Long‐Term Outcome in Patients With Severe Aortic Stenosis and Preserved Left Ventricular Ejection Fraction

Bohbot

Kowalski

Ruşinaru

et al. 2017

JAHA

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BackgroundMean transaortic pressure gradient (MTPG) has never been validated as a predictor of mortality in patients with severe aortic stenosis. We sought to determine the value of MTPG to predict mortality in a large prospective cohort of severe aortic stenosis patients with preserved left ventricular ejection fraction and to investigate the cutoff of 60 mm Hg, proposed in American guidelines.Methods and ResultsA total of 1143 patients with severe aortic stenosis defined by aortic valve area ≤1 cm2 and MTPG ≥40 mm Hg were included. The population was divided into 3 groups according to MTPG: between 40 and 49 mm Hg, between 50 and 59 mm Hg, and ≥60 mm Hg. The end point was all‐cause mortality. MTPG was ≥60 mm Hg in 392 patients. Patients with MTPG ≥60 mm Hg had a significantly increase risk of mortality compared with patients with MTPG <60 mm Hg (hazard ratio [HR]=1.62 [1.27–2.05] P<0.001), even for the subgroup of asymptomatic or minimally symptomatic patients (HR=1.56 [1.04–2.34] P=0.032). After adjustment for established outcome predictors, patients with MTPG ≥60 mm Hg had a significantly higher risk of mortality than patients with MTPG <60 mm Hg (HR=1.71 [1.33–2.20] P<0.001), even after adjusting for surgery as a time‐dependent variable (HR=1.71 [1.43–2.11] P<0.001). Similar results were observed for the subgroup of asymptomatic or minimally symptomatic patients (HR=1.70 [1.10–2.32] P=0.018 and HR=1.68 [1.20–2.36] P=0.003, respectively).ConclusionsThis study shows the negative prognostic impact of high MTPG (≥60 mm Hg), on long‐term outcome of patients with severe aortic stenosis with preserved left ventricular ejection fraction, irrespective of symptoms.

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Section: Discussionmentioning

confidence: 97%

Impact of Mean Transaortic Pressure Gradient on Long‐Term Outcome in Patients With Severe Aortic Stenosis and Preserved Left Ventricular Ejection Fraction

Bohbot

Kowalski

Ruşinaru

et al. 2017

JAHA

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“…Although a watchful waiting approach is generally justified in asymptomatic patients with severe AS, there are still concerns about when such a strategy should occur 27. Because improved surgical techniques have led to lower operative mortality and morbidity rates, earlier intervention has been increasingly advocated 3, 4, 5. Another recent report revealed that an initial SAVR strategy in patients with asymptomatic severe AS was associated with a lower risk for all‐cause mortality compared with a conservative watchful waiting approach 6.…”

Section: Discussionmentioning

confidence: 99%

“…According to recent Western guidelines, early invasive therapy is strongly recommended for symptomatic patients with severe AS because of their poor prognosis 1, 2. Based on the current low periprocedural mortality rates for isolated surgical aortic valve replacement (SAVR), earlier surgery for asymptomatic patients with severe AS has been increasingly advocated 3, 4, 5, 6. These studies suggest that early treatment of severe AS may improve the patient's prognosis.…”

Section: Introductionmentioning

confidence: 99%

Patients Refusing Transcatheter Aortic Valve Replacement Even Once Have Poorer Clinical Outcomes

Shimura

Yamamoto

Kano

et al. 2018

JAHA

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BackgroundAlthough transcatheter aortic valve replacement (TAVR) is the least invasive treatment for patients with symptomatic aortic stenosis, some patients hesitate to undergo the procedure. We investigated the clinical impact of treatment delay after patient refusal of TAVR.Methods and ResultsWe used the Japanese OCEAN (Optimized Catheter valvular intervention) regsitry data of 1542 patients who underwent TAVR. Refusal was defined as at least 1 refusal of TAVR at the time of informed consent. Patients were separated into 2 groups: refusal (28/1542, 1.8%) and non‐refusal (1514/1542, 98.2%). We compared the baseline characteristics, procedural outcomes, and mortality rates between the groups. Additionally, data on reasons for refusal and those leading to eventually undergoing TAVR were collected. Age, surgical risk scores, and frailty were higher in the refusal group than in the non‐refusal group (P<0.05 for all). Periprocedural complications did not differ between groups, whereas 30‐day and cumulative 1‐year mortality were significantly higher in the refusal group than in the non‐refusal group (7.1% versus 1.3%, P=0.008 and 28.8% versus 10.3%, P=0.010, respectively). Multivariate Cox regression analysis revealed that TAVR refusal was an independent predictor of increased midterm mortality (hazard ratio: 3.37; 95% confidence interval: 1.52–7.48; P=0.003). The most common reason for refusal was fear (13/28, 46.4%), and the most common reason for changing their mind was worsening heart failure (21/28, 75.0%). All patients in the refusal group decided to undergo TAVR within 20 months (median: 5.5 months).ConclusionsRefusing TAVR even once led to poorer prognosis; therefore, this fact should be clearly discussed when obtaining informed consent.

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“…Although the risk of sudden death in asymptomatic patients with severe AS is low (<1%/year), once symptomatic 3% of patients may die within 6 months, with an overall mortality of 50% over 2 years 3, 4, 5, 6. The decision about timing of AVR in patients with significant AS requires a careful assessment of the risk–benefit ratio of AVR versus watchful waiting.…”

Section: Introductionmentioning

confidence: 99%

Outcomes in Asymptomatic Severe Aortic Stenosis With Preserved Ejection Fraction Undergoing Rest and Treadmill Stress Echocardiography

Huded

Masri

Kusunose

et al. 2018

JAHA

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BackgroundIn asymptomatic patients with severe aortic stenosis and preserved left ventricular ejection fraction, we sought to assess the incremental prognostic value of resting valvuloarterial impedence (Zva) and left ventricular global longitudinal strain (LV‐GLS) to treadmill stress echocardiography.Methods and ResultsWe studied 504 such patients (66±12 years, 78% men, 32% with coronary artery disease who underwent treadmill stress echocardiography between 2001 and 2012. Clinical and exercise variables (% of age‐sex predicted metabolic equivalents [%AGP‐METs]) were recorded. Resting Zva ([systolic arterial pressure+mean aortic valve gradient]/[LV‐stroke volume index]) and LV‐GLS (measured offline using Velocity Vector Imaging, Siemens) were obtained from the baseline resting echocardiogram. Death was the primary outcome. There were no major adverse cardiac events during treadmill stress echocardiography. Indexed aortic valve area, Zva, and LV‐GLS were 0.46±0.1 cm2/m2, 4.5±0.9 mm Hg/mL per m2 and −16±4%, respectively; only 50% achieved >100% AGP‐METs. Sixty‐four percent underwent aortic valve replacement. Death occurred in 164 (33%) patients over 8.9±3.6 years (2 within 30 days of aortic valve replacement). On multivariable Cox survival analysis, higher Society of Thoracic Surgeons score (hazard ratio or HR 1.06), lower % AGP‐METS (HR 1.16), higher Zva (HR 1.25) and lower LV‐GLS (HR 1.12) were associated with higher longer‐term mortality, while aortic valve replacement (HR 0.45) was associated with improved survival (all P<0.01). Sequential addition of ZVa and LV‐GLS to clinical model (Society of Thoracic Surgeons score and %AGP‐METs) increased the c‐statistic from 0.65 to 0.69 and 0.75, respectively, both P<0.001); findings were similar in the subgroup of patients who underwent aortic valve replacement.ConclusionsIn asymptomatic patients with severe aortic stenosis undergoing treadmill stress echocardiography, LV‐GLS and ZVa offer incremental prognostic value.

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Outcome of 622 Adults With Asymptomatic, Hemodynamically Significant Aortic Stenosis During Prolonged Follow-Up

Abstract: Most patients with asymptomatic, hemodynamically significant AS will develop symptoms within 5 years. Sudden death occurs in approximately 1%/y. Age, chronic renal failure, inactivity, and aortic valve velocity are independently predictive of all-cause mortality.

Cited by 740 publications

References 19 publications

Impact of Mean Transaortic Pressure Gradient on Long‐Term Outcome in Patients With Severe Aortic Stenosis and Preserved Left Ventricular Ejection Fraction

Impact of Mean Transaortic Pressure Gradient on Long‐Term Outcome in Patients With Severe Aortic Stenosis and Preserved Left Ventricular Ejection Fraction

Patients Refusing Transcatheter Aortic Valve Replacement Even Once Have Poorer Clinical Outcomes

Outcomes in Asymptomatic Severe Aortic Stenosis With Preserved Ejection Fraction Undergoing Rest and Treadmill Stress Echocardiography

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