Staging classification of aortic stenosis based on the extent of cardiac damage

Abstract

AimsIn patients with aortic stenosis (AS), risk stratification for aortic valve replacement (AVR) relies mainly on valve-related factors, symptoms and co-morbidities. We sought to evaluate the prognostic impact of a newly-defined staging classification characterizing the extent of extravalvular (extra-aortic valve) cardiac damage among patients with severe AS undergoing AVR.Methods and resultsPatients with severe AS from the PARTNER 2 trials were pooled and classified according to the presence or absence of cardiac damage as detected by echocardiography prior to AVR: no extravalvular cardiac damage (Stage 0), left ventricular damage (Stage 1), left atrial or mitral valve damage (Stage 2), pulmonary vasculature or tricuspid valve damage (Stage 3), or right ventricular damage (Stage 4). One-year outcomes were compared using Kaplan–Meier techniques and multivariable Cox proportional hazards models were used to identify 1-year predictors of mortality. In 1661 patients with sufficient echocardiographic data to allow staging, 47 (2.8%) patients were classified as Stage 0, 212 (12.8%) as Stage 1, 844 (50.8%) as Stage 2, 413 (24.9%) as Stage 3, and 145 (8.7%) as Stage 4. One-year mortality was 4.4% in Stage 0, 9.2% in Stage 1, 14.4% in Stage 2, 21.3% in Stage 3, and 24.5% in Stage 4 (Ptrend < 0.0001). The extent of cardiac damage was independently associated with increased mortality after AVR (HR 1.46 per each increment in stage, 95% confidence interval 1.27–1.67, P < 0.0001).ConclusionThis newly described staging classification objectively characterizes the extent of cardiac damage associated with AS and has important prognostic implications for clinical outcomes after AVR.

Haemodynamic mechanisms and long‐term prognostic impact of pulmonary hypertension in patients with severe aortic stenosis undergoing valve replacement

“…The CpcPH group had the worst right ventricular function as expressed by TAPSE, an established prognostic marker in various settings, and reflected by the highest right atrial pressure and right ventricular end‐diastolic pressure. The presence of right ventricular dysfunction represents the most advanced stage of AS, which is associated with poor prognosis . There is relatively recent evidence that in patients with severe AS, PH often persists after AVR, and that post‐AVR PH is a more important prognostic predictor than pre‐AVR PH .…”

“…The presence of right ventricular dysfunction represents the most advanced stage of AS, which is associated with poor prognosis. 3 There is relatively recent evidence that in patients with severe AS, PH often persists after AVR, 5,6 and that post-AVR PH is a more important prognostic predictor than pre-AVR PH. 5 Since this information is derived from echocardiographic studies, the detailed haemodynamic pattern prior and post AVR of these patients remains unknown.…”

“…In patients with severe aortic stenosis (AS), PH is frequent and a marker of poor prognosis . However, the majority of data on PH in AS patients are derived from echocardiography studies, where systolic pulmonary artery pressure (PAP) is estimated by measurement of peak tricuspid regurgitation velocity. This together with indirect signs of PH gives a reasonable estimate of the probability of significant PH 7 but does not allow assessing the underlying haemodynamic mechanisms of PH in detail …”

Correlation between Doppler echocardiography and right heart catheterization assessment of systolic pulmonary artery pressure in patients with severe aortic stenosis

“…1 Pulmonary hypertension (PH) is a common finding in patients with AS, especially postcapillary PH due to left heart disease, the most common type of PH. [2][3][4][5][6][7][8][9][10][11] Pulmonary hypertension is a sign of advanced cardiac damage due to severity of AS according to damage stages 3 and 4 as described by Genereux et al 12 Previous studies in patients with PH showed an increased mortality after aortic valve replacement (AVR) and PH to be a marker for poor prognosis. 6,7,[9][10][11]13,14 Therefore, assessment of PH is important for risk stratification, with PH being one of the components of the logistic EuroSCORE and the EuroSCORE II.…”

High-Sensitivity C-Reactive Protein in Transcatheter Aortic Valve Implantation: Prognostic Biomarker and New Potential Therapeutic Avenue

“…9 ) Thus, stroke remains the most devastating complication of TAVI. Since the prognosis of patients who benefit the most from TAVI is likely not only determined by AS severity, but also by multiple comorbidities, and possibly by the extent of extravalvular cardiac damage, 10 biomarkers that would implement clinical scores to identify patients at risk of major cardiovascular events, including stroke, or death could be very useful. Importantly, although valve replacement clearly improves patient outcome, 11,12 baseline comorbidities if left sub-optimally treated or myocardial damage might indeed, in specific cases, be the main cause of poor outcome.…”