Reduced Left Ventricular Ejection Fraction in Patients With Aortic Stenosis

Ito, Saki; Miranda, William R.; Nkomo, Vuyisile T.; Connolly, Heidi M.; Pislaru, Sorin V.; Greason, Kevin L.; Pellikka, Patricia A.; Lewis, Bradley R.; Oh, Jae K.

doi:10.1016/j.jacc.2018.01.045

Cited by 144 publications

(76 citation statements)

References 33 publications

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“…Therefore, there may be an underlying myocardial process predisposing this group of patients to developing LV maladaptation to increased LV afterload when AS severity is only moderate. 30 A main finding of this study was additionally the demonstration that concentric remodeling had a negative prognostic impact even Increased RWT in individuals with normal LV mass (ie, concentric remodeling) has often been considered as the earliest phase of the LV concentric adaptive response to pressure overload. Indeed, animal models showed that the heart can tolerate pressure overload even without hypertrophy under some conditions 32 and that the level of LVH does not necessarily correlate with the extent of cardiac dysfunction.…”

Section: Discussionmentioning

confidence: 68%

“…Recent findings suggest that the normal EF for patients with AS should be at least 60%, and an LVEF < 60% should alert clinicians to the possibility of superimposed myocardial dysfunction. 30 In our cohort, although the total number of patients is quite impressive for a single center, the absolute number in each group is quite small with suboptimal power to actually be able to show differences between the groups. Therefore, a prospective and multicenter study is needed to confirm and further expand these findings.…”

Section: Study Limitationsmentioning

confidence: 71%

“…Recent data suggest that EF began to deteriorate before AS became severe and accelerated when AVA reached 1.2 cm 2 . Therefore, there may be an underlying myocardial process predisposing this group of patients to developing LV maladaptation to increased LV afterload when AS severity is only moderate …”

Section: Discussionmentioning

confidence: 99%

“…However, the transition from preserved to reduced EF and a clear cutoff for an abnormal EF in patients with AS have not been well studied. Recent findings suggest that the normal EF for patients with AS should be at least 60%, and an LVEF < 60% should alert clinicians to the possibility of superimposed myocardial dysfunction …”

Section: Discussionmentioning

confidence: 99%

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Remodeling classification system considering left ventricular volume in patients with aortic valve stenosis: Association with adverse cardiovascular outcomes

et al. 2019

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Background To assess prevalence and clinical implications of left ventricular (LV) remodeling considering: LV volume, mass and relative wall thickness at the time of aortic valve stenosis diagnosis. Methods and Results We retrospectively analyzed 343 patients (age 79.2 ± 9.5 years, 48.1% males) with functional aortic valve area (AVA) ≤ 1.5 cm2. LV geometric patterns and clinical outcomes (combined death, cardiac hospitalization, aortic valve replacement [AVR]) were evaluated. According to the new LV remodeling classification, 4.9% had normal geometry, 7.5% concentric remodeling, 39.3% concentric hypertrophy (LVH), 22.4% mixed LVH, 12.5% dilated LVH, 3.2% eccentric LVH and 4.3% eccentric remodeling, 5.5% had not classifiable LVH. Indexed stroke volume (SVi) was higher in patients with concentric LVH (40.3 ± 11.9 mL/m2) and mixed LVH (41.6 ± 13.4 mL/m2) and lower in patients with eccentric LVH (24.9 ± 7.7 mL/m2), concentric (36.6 ± 12.7 mL/m2) and eccentric remodeling (34.9 ± 9.5 mL/m2), P = 0.003. During a median follow‐up of 2.2 years, 260 (75.8%) had the combined end point. A significant association between the combined end point and LV dilation (P = 0.010) or LV remodeling patterns (P = 0.0001) was found. After multivariable adjustment for AVR, concentric remodeling (HR 3.12, IC 95% 1.14–8.55; P = 0.02) and dilated LVH (HR 3.48, IC 95% 1.31–9.27; P = 0.01) were strongly associated with death or cardiac hospitalizations. Conclusions In patients with AVA ≤ 1.5 cm2, when the new LV remodeling classification system is applied, only a minority had normal geometry and less than half had “classic” concentric LVH or remodeling. LV volume dilatation is frequent and associated with adverse outcome. Concentric remodeling, eccentric remodeling, dilated LVH had the worst noninvasive hemodynamic profile and prognosis.

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Section: Discussionmentioning

confidence: 68%

Section: Study Limitationsmentioning

confidence: 71%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Remodeling classification system considering left ventricular volume in patients with aortic valve stenosis: Association with adverse cardiovascular outcomes

et al. 2019

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“…anemia, hyperthyreosis, etc.). In general, underestimation of AS severity by determining V max AS and ΔP mean AS may occur during low flow conditions, reduced LVSV and reduced LV function [17][18][19][20], overestimation during hyperdynamic circulatory states and by pressure recovery [21][22][23][24]. Pressure recovery describes the phenomenon of conversion of kinetic energy within the AS narrowing into pressure energy in the aortic root and the ascending aorta [23,25].…”

Section: Peak Jet Velocity (V Max As) and Mean Pressure Gradient (δPmentioning

confidence: 99%

Expert consensus document on the assessment of the severity of aortic valve stenosis by echocardiography to provide diagnostic conclusiveness by standardized verifiable documentation

Hagendorff¹,

Knebel²,

Helfen

et al. 2019

Clin Res Cardiol

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According to recent recommendations on echocardiographic assessment of aortic valve stenosis direct measurement of transvalvular peak jet velocity, calculation of transvalvular mean gradient from the velocities using the Bernoulli equation and calculation of the effective aortic valve area by continuity equation are the appropriate primary key instruments for grading severity of aortic valve stenosis. It is obvious that no gold standard can be declared for grading the severity of aortic stenosis. Thus, conclusions of the exclusive evaluation of aortic stenosis by Doppler echocardiography seem to be questionable due to the susceptibility to errors caused by methodological limitations, mathematical simplifications and inappropriate documentation. The present paper will address practical issues of echocardiographic documentation to satisfy the needs to analyze different scenarios of aortic stenosis due to various flow conditions and pressure gradients. Transesophageal and multidimensional echocardiography should be implemented for reliable measurement of geometric aortic valve area and of cardiac dimensions at an early stage of the diagnostic procedure to avoid misinterpretation due to inconsistent results.

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Association Between Early Left Ventricular Ejection Fraction Improvement After Transcatheter Aortic Valve Replacement and 5-Year Clinical Outcomes

Kolte

Bhardwaj

et al. 2022

JAMA Cardiol

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In patients with severe aortic stenosis and left ventricular ejection fraction (LVEF) less than 50%, early LVEF improvement after transcatheter aortic valve replacement (TAVR) is associated with improved 1-year mortality; however, its association with long-term clinical outcomes is not known.OBJECTIVE To examine the association between early LVEF improvement after TAVR and 5-year outcomes. DESIGN, SETTING, AND PARTICIPANTSThis cohort study analyzed patients enrolled in the Placement of Aortic Transcatheter Valves (PARTNER) 1, 2, and S3 trials and registries between July 2007 and April 2015. High-and intermediate-risk patients with baseline LVEF less than 50% who underwent transfemoral TAVR were included in the current study. Data were analyzed from August 2020 to May 2021.EXPOSURES Early LVEF improvement, defined as increase of 10 percentage points or more at 30 days and also as a continuous variable (ΔLVEF between baseline and 30 days). MAIN OUTCOMES AND MEASURESAll-cause death at 5 years. RESULTS Among 659 included patients with LVEF less than 50%, 468 (71.0%) were male, and the mean (SD) age was 82.4 (7.7) years. LVEF improvement within 30 days following transfemoral TAVR occurred in 216 patients (32.8%) (mean [SD] ΔLVEF, 16.4 [5.7%]). Prior myocardial infarction, diabetes, cancer, higher baseline LVEF, larger left ventricular end-diastolic diameter, and larger aortic valve area were independently associated with lower likelihood of LVEF improvement. Patients with vs without early LVEF improvement after TAVR had lower 5-year all-cause death ( 102[50.0%; 95% CI, 43.3-57.1] vs 246 [58.4%; 95% CI, 53.6-63.2]; P = .04) and cardiac death (52 [29.5%; 95% CI, 23.2-37.1] vs 135 [38.1%; 95% CI,]; P = .05). In multivariable analyses, early improvement in LVEF (modeled as a continuous variable) was associated with lower 5-year all-cause death (adjusted hazard ratio per 5% increase in LVEF, 0.94 [95% CI, 0.88-1.00]; P = .04) and cardiac death (adjusted hazard ratio per 5% increase in LVEF, 0.90 [95% CI, 0.82-0.98]; P = .02) after TAVR. Restricted cubic spline analysis demonstrated a visual inflection point at ΔLVEF of 10% beyond which there was a steep decline in all-cause mortality with increasing degree of LVEF improvement. There were no statistically significant differences in rehospitalization, New York Heart Association functional class, or Kansas City Cardiomyopathy Questionnaire Overall Summary score at 5 years in patients with vs without early LVEF improvement. In subgroup analysis, the association between early LVEF improvement and 5-year all-cause death was consistent regardless of the presence or absence of coronary artery disease or prior myocardial infarction. CONCLUSIONS AND RELEVANCEIn patients with severe aortic stenosis and LVEF less than 50%, 1 in 3 experience LVEF improvement within 1 month after TAVR. Early LVEF improvement is associated with lower 5-year all-cause and cardiac death.

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Reduced Left Ventricular Ejection Fraction in Patients With Aortic Stenosis

Cited by 144 publications

References 33 publications

Remodeling classification system considering left ventricular volume in patients with aortic valve stenosis: Association with adverse cardiovascular outcomes

Remodeling classification system considering left ventricular volume in patients with aortic valve stenosis: Association with adverse cardiovascular outcomes

Expert consensus document on the assessment of the severity of aortic valve stenosis by echocardiography to provide diagnostic conclusiveness by standardized verifiable documentation

Association Between Early Left Ventricular Ejection Fraction Improvement After Transcatheter Aortic Valve Replacement and 5-Year Clinical Outcomes

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