Percent left ventricular stroke work loss: A simplified hemodynamic concept for assessment of valvular aortic stenosis

Tobin, John R.; Rahimtoola, Shahbudin H.; Blundell, Peter E.; Swan, H. J. C.

doi:10.1016/0002-9149(66)90337-7

Cited by 19 publications

(26 citation statements)

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“…This may include transesophageal echocardiography, 31 magnetic resonance imaging, 32 and, rarely, cardiac catheterization, 33 as outlined in the American Heart Association/ American College of Cardiology and European Society of Cardiology guidelines. 10 -12 Several additional echocardiographic parameters have been proposed for a better definition of the severity of aortic stenosis and imminent risk (energy loss index, 34,35 stroke work loss, 36,37 resistance, 38 and valvuloarterial impedance 39,40 ), but their utility and prognostic impact still must be proven in larger-scale, prospective studies. Indication for valve replacement in patients with low-gradient "severe" aortic stenosis may currently be restricted to those in whom symptoms can clearly be attributed to aortic valve disease.…”

Section: Discussionmentioning

confidence: 99%

Outcome of Patients With Low-Gradient “Severe” Aortic Stenosis and Preserved Ejection Fraction

et al. 2011

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Background— Retrospective studies have suggested that patients with a low transvalvular gradient in the presence of an aortic valve area <1.0 cm 2 and normal ejection fraction may represent a subgroup with an advanced stage of aortic valve disease, reduced stroke volume, and poor prognosis requiring early surgery. We therefore evaluated the outcome of patients with low-gradient “severe” stenosis (defined as aortic valve area <1.0 cm 2 and mean gradient ≤40 mm Hg) in the prospective Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study. Methods and Results— Outcome in patients with low-gradient “severe” aortic stenosis was compared with outcome in patients with moderate stenosis (aortic valve area 1.0 to 1.5 cm 2 ; mean gradient 25 to 40 mm Hg). The primary end point of aortic valve events included death from cardiovascular causes, aortic valve replacement, and heart failure due to aortic stenosis. Secondary end points were major cardiovascular events and cardiovascular death. In 1525 asymptomatic patients (mean age, 67±10 years; ejection fraction, ≥55%), baseline echocardiography revealed low-gradient severe stenosis in 435 patients (29%) and moderate stenosis in 184 (12%). Left ventricular mass was lower in patients with low-gradient severe stenosis than in those with moderate stenosis (182±64 versus 212±68 g; P <0.01). During 46 months of follow-up, aortic valve events occurred in 48.5% versus 44.6%, respectively ( P =0.37; major cardiovascular events, 50.9% versus 48.5%, P =0.58; cardiovascular death, 7.8% versus 4.9%, P =0.19). Low-gradient severe stenosis patients with reduced stroke volume index (≤35 mL/m 2 ; n=223) had aortic valve events comparable to those in patients with normal stroke volume index (46.2% versus 50.9%; P =0.53). Conclusions— Patients with low-gradient “severe” aortic stenosis and normal ejection fraction have an outcome similar to that in patients with moderate stenosis.

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Section: Discussionmentioning

confidence: 99%

Outcome of Patients With Low-Gradient “Severe” Aortic Stenosis and Preserved Ejection Fraction

et al. 2011

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“…Early hemodynamic studies including significant number of congenital AS have shown that patients with AS and AVA <1 cm 2 have dismal outcome 7 and suggested that AVA should be corrected by BSA. 6,23 Although contemporary outcome data supporting the prognostic value of AVA/BSA are scant, 9,24 US and European guidelines 1,2 have included AVA/BSA among criteria for grading AS severity (ie, AVA/BSA <0.6 cm 2 /m 2 ). In a study including 103 asymptomatic patients with, AS, AVA/BSA 24 Jander et al 9 have recently shown that among patients with AS the number of patients with AVA/BSA <0.6 cm 2 /m 2 is significantly greater than the number of patients with AVA <1 cm 2 and that the predictive accuracy for aortic valve events of the 2 parameters is almost identical.…”

Section: Discussionmentioning

confidence: 99%

“…The reliability of AVA/BSA as diagnostic parameter in AS is subject to debate because of the confounding effect of the acquired fat tissue that does not interact with AVA. 5 Moreover, the 0.6 cm 2 /m 2 AVA/BSA guideline-recommended cutoff is based on old studies including limited number of patients [6][7][8] and has not been validated to date by outcome studies. Recently, in the SEAS (Simvastatin and Ezetimibe in Aortic Stenosis) population, it has been shown that the use of the 0.6 cm 2 /m 2 cutoff increases by ≈10% the frequency of severe AS compared with the 1 cm 2 AVA cutoff.…”

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confidence: 99%

Outcome Implication of Aortic Valve Area Normalized to Body Size in Asymptomatic Aortic Stenosis

Tribouilloy

Bohbot

Maréchaux

et al. 2016

Circ: Cardiovascular Imaging

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Background— Current guidelines define severe aortic stenosis in patients with aortic valve area normalized to body surface area (AVA/BSA) <0.6 cm 2 /m 2 ; yet, this cutoff has never been validated. Moreover, it is not known whether AVA normalization to other body size indexes allows improved outcome prediction. We aim to test the value of AVA normalized to body size for outcome prediction in asymptomatic aortic stenosis. Methods and Results— We included 289 patients with asymptomatic aortic stenosis, preserved ejection fraction, and AVA<1.3 cm 2 at diagnosis. The outcome measure was the occurrence of aortic valve replacement or all-cause death or during follow-up. AVA was normalized to BSA, height, weight, and body mass index. For each normalized index, patients in the lowest tertile were at high risk of events whereas outcome was similar for the other tertiles. High risk of events was observed with AVA/BSA <0.4 cm 2 /m 2 (adjusted hazard ratio [HR], 3.42 [2.09–5.60]), AVA/height <0.45 cm 2 /m (adjusted HR, 3.99 [2.42–6.60]), AVA/weight <0.01 cm 2 /kg (adjusted HR, 3.37 [2.07–5.49]), and AVA/body mass index <0.029 cm 2 /kg per meter square (adjusted HR, 3.23 [1.99–5.24]). Mortality risk was high with AVA/height <0.45 cm 2 /m (adjusted HR, 2.18 [1.28–3.71]), followed by AVA/BSA <0.40 cm 2 /m 2 (adjusted HR, 1.84 [1.09–3.11]), AVA/weight <0.01 cm 2 /kg (adjusted HR, 1.78 [1.07–2.98]), and AVA/body mass index <0.029 cm 2 /kg per meter square (adjusted HR, 1.75 [1.04–2.93]). AVA/height showed better predictive performance than AVA/BSA with improved reclassification and better discrimination (net reclassification improvement: 0.33 versus 0.28; integrated discrimination improvement: 0.10 versus 0.08; C statistic: 0.67 versus 0.65), whereas AVA/weight and AVA/body mass index showed lower predictive capacity. Conclusions— Among AVA normalization methods, AVA/height <0.45 cm 2 /m followed by AVA/BSA <0.40 cm 2 /m 2 seem as robust parameters for defining high risk in asymptomatic aortic stenosis. The prognostic value of AVA/height deserves future research.

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“…[1][2][3][4][5] Grading of AS severity was originally derived from cardiac catheterization data, which take pressure recovery into account, and then extrapolated to Doppler echocardiography. [23][24][25][26][27] Because Doppler echocardiography has become the standard method for evaluating AS severity in current practice, 1,4 adjustment for pressure recovery in the aortic root has been suggested for milder degrees of AS to prevent overestimation of AS severity. 7,9,19 To the best of our knowledge, this is the first study to assess the prognostic value of ELI in a large prospective study of initially asymptomatic AS patients.…”

Section: Discussionmentioning

confidence: 99%

Prognostic Value of Energy Loss Index in Asymptomatic Aortic Stenosis

et al. 2013

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Background— Aortic valve area index adjusted for pressure recovery (energy loss index [ELI]) has been suggested as a more accurate measure of aortic stenosis (AS) severity, but its prognostic value has not been determined in a prospective study. Methods and Results— The relation between baseline ELI and rate of aortic valve events and combined total mortality and hospitalization for heart failure resulting from the progression of AS was assessed by multivariate Cox regression and reclassification analysis in 1563 patients with initial asymptomatic AS in the Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study. During 4.3 years follow-up, a total of 498 aortic valve events and 181 combined total mortalities and hospitalizations for heart failure caused by the progression of AS occurred. In Cox regression analyses, 1-cm 2 /m 2 lower baseline ELI predicted a 2-fold higher risk both for aortic valve events and for combined total mortality and hospitalization for heart failure independently of baseline peak aortic jet velocity or mean aortic gradient and independently of aortic root size (all P <0.05). In reclassification analysis, ELI improved the prediction of aortic valve events by 13% (95% confidence interval, 5–19), whereas the prediction of combined total mortality and hospitalization for heart failure resulting from the progression of AS did not improve significantly. Conclusions— In asymptomatic AS patients without known atherosclerotic disease or diabetes mellitus, ELI provides independent and additional prognostic information to that derived from conventional measures of AS severity, suggesting that ELI should be measured in such patients. Clinical Trial Registration Information— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00092677.

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Percent left ventricular stroke work loss: A simplified hemodynamic concept for assessment of valvular aortic stenosis

Cited by 19 publications

References 0 publications

Outcome of Patients With Low-Gradient “Severe” Aortic Stenosis and Preserved Ejection Fraction

Outcome of Patients With Low-Gradient “Severe” Aortic Stenosis and Preserved Ejection Fraction

Outcome Implication of Aortic Valve Area Normalized to Body Size in Asymptomatic Aortic Stenosis

Prognostic Value of Energy Loss Index in Asymptomatic Aortic Stenosis

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