Progression of Normal Flow Low Gradient “Severe” Aortic Stenosis With Preserved Left Ventricular Ejection Fraction

Chadha, Gagandeep; Bohbot, Yohann; Lachambre, Pierre; Ruşinaru, Dan; Serbout, Saousan; Altes, Alexandre; Pasquet, Agnès; Maréchaux, Sylvestre; Vanoverschelde, Jean–Louis; Tribouilloy, Christophe

doi:10.1016/j.amjcard.2020.05.003

Cited by 13 publications

(12 citation statements)

References 35 publications

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“…The thickness and volume of NF-LG-SAS cusps were significantly lower than those of HG-SAS. Consequently, all the structural parameters quantified in our work support several previously published studies that evaluate NF-LG-SAS as a less advanced AS progression than other severe AS cases ( 39 , 42 – 46 ). Since AS classification contains several controversial subgroups, the imaging approach described in this study could be used to better characterize and understand each AS phenotype.…”

Section: Discussionsupporting

confidence: 87%

“…As case study in our work, the quantitative structural analysis we performed was applied to two patient groups: NF-LG-SAS and HG-SAS to determine whether they were structurally different from each other and to evaluate whether ex vivo microCT could be used to better understand the particular case of NF-LG-SAS diagnosis. The medical prognosis of NF-LG-SAS is still under discussion and it is still not clear whether NF-LG-SAS is a truly severe AS, as calcified as HG-SAS or whether it is an intermediate stage of AS in which calcifications will still increase and result in high pressure gradient (26,(38)(39)(40)(41)(42). The summary scheme outlines the main differences observed between the two diagnosis groups (Figure 6B).…”

Section: Discussionmentioning

confidence: 99%

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3D histopathology of stenotic aortic valve cusps using ex vivo microfocus computed tomography

Pestiaux¹,

Pyka²,

Quirynen³

et al. 2023

Front. Cardiovasc. Med.

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BackgroundCalcific aortic stenosis (AS) is the most prevalent heart valve disease in developed countries. The aortic valve cusps progressively thicken and the valve does not open fully due to the presence of calcifications. In vivo imaging, usually used for diagnosis, does not allow the visualization of the microstructural changes associated with AS.MethodsEx vivo high-resolution microfocus computed tomography (microCT) was used to quantitatively describe the microstructure of calcified aortic valve cusps in full 3D. As case study in our work, this quantitative analysis was applied to normal-flow low-gradient severe AS (NF-LG-SAS), for which the medical prognostic is still highly debated in the current literature, and high-gradient severe AS (HG-SAS).ResultsThe volume proportion of calcification, the size and number of calcified particles and their density composition was quantified. A new size-based classification considering small-sized particles that are not detected with in vivo imaging was defined for macro-, meso- and microscale calcifications. Volume and thickness of aortic valve cusps, including the complete thickness distribution, were also determined. Moreover, changes in the cusp soft tissues were also visualized with microCT and confirmed by scanning electron microscopy images of the same sample. NF-LG-SAS cusps contained lower relative amount of calcifications than HG-SAS. Moreover, the number and size of calcified objects and the volume and thickness of the cusps were also lower in NF-LG-SAS cusps than in HG-SAS.ConclusionsThe application of high-resolution ex vivo microCT to stenotic aortic valve cusps provided a quantitative description of the general structure of the cusps and of the calcifications present in the cusp soft tissues. This detailed description could help in the future to better understand the mechanisms of AS.

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Section: Discussionsupporting

confidence: 87%

Section: Discussionmentioning

confidence: 99%

3D histopathology of stenotic aortic valve cusps using ex vivo microfocus computed tomography

Pestiaux¹,

Pyka²,

Quirynen³

et al. 2023

Front. Cardiovasc. Med.

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“…Current guidelines are still mainly based on EOA and transaortic gradients. In cases of discordance between these parameters, flow status needs to be determined, since normal-flow low-gradient AS has a prognosis like that of moderate AS [ 24 , 25 , 26 , 27 ] and better than that of low-flow low-gradient or high-gradient AS [ 24 , 25 , 26 , 28 ]. However, optimal management remains unclear as other studies reported a benefit of AVR in this population [ 29 ].…”

Section: Discussionmentioning

confidence: 99%

Energy Loss Index and Dimensionless Index Outperform Direct Valve Planimetry in Low-Gradient Aortic Stenosis

Hugelshofer,

de Brito,

Antiochos

et al. 2024

JCM

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Background/Objectives: Among patients with suspected severe aortic stenosis (AS), discordance between effective orifice area (EOA) and transvalvular gradients is frequent and requires a multiparametric workup including flow assessment and calcium-scoring to confirm true severe AS. The aim of this study was to assess direct planimetry, energy loss index (Eli) and dimensionless index (DI) as stand-alone parameters to identify non-severe AS in discordant cases. Methods: In this prospective cohort study, we included consecutive AS patients > 70 years with EOA < 1.0 cm2 referred for valve replacement between 2014 and 2017. AS severity was retrospectively reassessed using the multiparametric work-up recommended in the 2021 ESC/EACTS guidelines. DI and ELi were calculated, and valve area was measured by direct planimetry on transesophageal echocardiography. Results: A total of 101 patients (mean age 82 y; 57% male) were included. Discordance between EOA and gradients was observed in 46% and non-severe AS found in 24% despite an EOA < 1 cm2. Valve planimetry performed poorly, with an area under the ROC curve (AUC) of 0.64. At a cut-off value of >0.82 cm2, sensitivity and specificity to identify non-severe AS were 67 and 66%, respectively. DI and ELi showed a higher diagnostic accuracy, with an AUC of 0.77 and 0.76, respectively. Cut-off values of >0.24 and >0.6 cm2/m2 identified non-severe AS, with a high specificity of 79% and 91%, respectively. Conclusions: Almost one in four patients with EOA < 1 cm2 had non-severe AS according to guideline-recommended multiparametric assessment. Direct valve planimetry revealed poor diagnostic accuracy and should be interpreted with caution. Usual prognostic cut-off values for DI > 0.24 and ELI > 0.6 cm2/m2 identified non-severe AS with high specificity and should therefore be included in the assessment of low-gradient AS.

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“… 38 Risk factors associated with the progression of tricuspid aortic valve stenosis are similar to those for atherosclerosis. 39 Regarding the progression of NFLG-SAS, the latest report by Chadha et al 40 demonstrated that 48% of patients diagnosed with NFLG-SAS progressed to high-gradient SAS during a median follow-up of 25 months. In addition, a propensity-matched study of NFLG-SAS conducted by Chadha et al 12 demonstrated that patients with NFLG-SAS required AVR significantly earlier than those with moderate AS during a 24-month follow-up.…”

Section: Discussionmentioning

confidence: 99%

Left Ventricular Hypertrophic Change Indicating Poor Prognosis in Patients With Normal-Flow, Low-Gradient Severe Aortic Stenosis With Preserved Left Ventricular Ejection Fraction

et al. 2021

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Background: Risk stratification of normal-flow, low-gradient (NFLG) severe aortic stenosis (SAS) with preserved left ventricular (LV) ejection fraction (EF) remains unclear. Methods and Results: Of 289 consecutive patients diagnosed with SAS by aortic valve area <1.0 cm 2 , 66 with NFLG-SAS (stroke volume index >35 mL/m 2 , mean pressure gradient <40 mmHg, LVEF ≥50%) were enrolled in this study; patients with bicuspid aortic valve, acute coronary syndrome, hemodialysis, or a history of aortic valve replacement (AVR) were excluded. Adverse events (AEs) were defined as cardiovascular death, hospitalization for heart failure, and deteriorating condition requiring AVR. Factors associated with AEs were investigated using a Cox proportional hazards model. Over a median of 675 days of follow-up, 25 AEs were recorded: 4 cardiovascular deaths, 12 hospitalizations for heart failure, and 9 patients requiring AVR. In addition, there were 14 events of progression to high-gradient SAS. Multivariable analysis showed significant associations between AEs and the presence of symptoms (hazard ratio [HR] 10.276; 95% confidence interval [CI] 3.724–28.357; P<0.001), LV hypertrophy (LV mass index >115 and >95 mg/m 2 for males and females, respectively; HR 3.257; 95% CI 1.172–9.050; P=0.024), and tricuspid regurgitation (TR) velocity (HR 2.761; 95% CI 1.246–6.118; P=0.012). Conclusions: The presence of symptoms, LV hypertrophy, and high TR velocity could be reliable prognostic indicators and may require watchful waiting for timely AVR in patients with NFLG-SAS.

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Progression of Normal Flow Low Gradient “Severe” Aortic Stenosis With Preserved Left Ventricular Ejection Fraction

Cited by 13 publications

References 35 publications

3D histopathology of stenotic aortic valve cusps using ex vivo microfocus computed tomography

3D histopathology of stenotic aortic valve cusps using ex vivo microfocus computed tomography

Energy Loss Index and Dimensionless Index Outperform Direct Valve Planimetry in Low-Gradient Aortic Stenosis

Left Ventricular Hypertrophic Change Indicating Poor Prognosis in Patients With Normal-Flow, Low-Gradient Severe Aortic Stenosis With Preserved Left Ventricular Ejection Fraction

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