Going beyond classic echo in aortic stenosis: left atrial mechanics, a new marker of severity

et al. 2021

Cardiovasc Ultrasound

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Background Aortic valve stenosis (AS) is the most common primary valvular heart disease leading to surgical or percutaneous aortic valve replacement (AVR) in Europe and its prevalence keeps growing. While other risk factors in severe AS are well documented, little is known about the prognostic value of left atrial (LA) function in AS. Our aim is to clarify the relationship between LA function measured at severe AS diagnosis (evaluated by means of volumetric assessment) and all-cause mortality during follow-up. Methods We retrospectively evaluated patients diagnosed with severe AS for the first time at our echocardiography laboratory. We evaluated LA reservoir, conduit and pump function by measuring LA volumes at different timings of cardiac cycle. Treatment strategy was decided according to heart team consensus and patient decision. We divided patients into groups according to terciles of LA reservoir, conduit and pump function. Primary outcome was defined by the occurrence of all-cause mortality during follow-up. Results A total of 408 patients were included in the analysis, with a median follow-up time of 45 months (interquartile range 54 months). 57.9% of patients underwent AVR and 44.9% of patients registered the primary outcome during follow-up. Left atrial emptying fraction (LAEF) was the best LA functional parameter and the best overall parameter in discriminating primary outcome (AUC 0.845, 95%CI 0.81–0.88, P < 0.001). After adjustment for clinical, demographic and echocardiographic variables, cumulative survival of patients with LAEF < 37% and LAEF 37 to 53% relative to patients with LAEF ≥54% remained significantly lower (HR 13.91, 95%CI 6.20–31.19, P < 0.001 and HR 3.40, 95%CI 1.57–7.37, P = 0.002, respectively). After adjustment for AVR, excess risk of LAEF < 37% and LAEF 37 to 53% relative to LAEF ≥54% remained significant (HR 11.71, 95%CI 5.20–26.40, P < 0.001 and HR 3.59, 95%CI 1.65–7.78, P = 0.001, respectively). Conclusions In patients with a first diagnosis of severe AS, LA function, evaluated by means of volumetric assessment, is an independent predictor of all-cause mortality and a more potent predictor of death compared to classical severity parameters. These data can be useful to identify high-risk patients who might benefit of AVR.

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Left atrial functional assessment and mortality in patients with severe aortic stenosis with sinus rhythm

et al. 2021

Cardiovasc Ultrasound

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“…There have been some reports showing that LA function assessed by speckle-tracking echocardiography can predict worse outcomes in AS patients. In a study conducted in our center, Marques-Alves et al found that, in a population of patients with moderate and severe AS, LA global strain was the best discriminator of AS severity and a signi cant predictor of a composite of HF, death and AVR [19]. The same study also found that atrial mechanics were better predictors of prognosis that LV global longitudinal strain, which was not a signi cant predictor of outcome.…”

Section: Discussionmentioning

confidence: 90%

“…Other published studies that addressed the impact of LA function on prognosis used as outcome a composite of HF, death and AVR [19], occurrence of symptoms and death [20] and major adverse cardiac events [21], outcomes that can be broad. In our study, the measured outcome was all-cause mortality, still, the best predictor of outcome found (LAEF representing LA reservoir function) showed very good predictive value.…”

Section: Discussionmentioning

confidence: 99%

Left atrial functional assessment and mortality in patients with severe aortic stenosis with sinus rhythm

et al. 2020

Preprint

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Background: Aortic valve stenosis (AS) is the most common primary valvular heart disease leading to surgical or percutaneous aortic valve replacement (AVR) in Europe and its prevalence keeps growing. While other risk factors in severe AS are well documented, little is known about the prognostic value of left atrial (LA) function in AS. Our aim is to clarify the relationship between LA function measured at severe AS diagnosis (evaluated by means of volumetric assessment) and all-cause mortality during follow-up. Methods: We retrospectively evaluated patients diagnosed with severe AS for the first time at our echocardiography laboratory. We evaluated LA reservoir, conduit and pump function by measuring LA volumes at different timings of cardiac cycle. Treatment strategy was decided according to heart team consensus and patient decision. We divided patients into groups according to terciles of LA reservoir, conduit and pump function. Primary outcome was defined by the occurrence of all-cause mortality during follow-up. Results: A total of 408 patients were included in the analysis, with a median follow-up time of 45 months (interquartile range 54 months). 57.9% of patients underwent AVR and 44.9% of patients registered the primary outcome during follow-up. Left atrial emptying fraction (LAEF) was the best LA functional parameter and the best overall parameter in discriminating primary outcome (AUC 0.845, 95%CI 0.81-0.88, P <0.001). After adjustment for clinical, demographic and echocardiographic variables, cumulative survival of patients with LAEF <37% and LAEF 37 to 53% relative to patients with LAEF ≥54% remained significantly lower (HR 13.91, 95%CI 6.20-31.19, P <0.001 and HR 3.40, 95%CI 1.57-7.37, P =0.002, respectively). After adjustment for AVR, excess risk of LAEF <37% and LAEF 37 to 53% relative to LAEF ≥54% remained significant (HR 11.71, 95%CI 5.20-26.40, P <0.001 and HR 3.59, 95%CI 1.65-7.78, P =0.001, respectively). Conclusions: In patients with a first diagnosis of severe AS, LA function, evaluated by means of volumetric assessment, is an independent predictor of all-cause mortality and a more potent predictor of death compared to classical severity parameters. These data can be useful to identify high-risk patients who might benefit of AVR.

“…Other published studies that addressed the impact of LA function on prognosis used as outcome a composite of heart failure, death and AVR [19], occurrence of symptoms and death [20] and major adverse cardiac events [21], outcomes that can be broad. In our study, the measured outcome was allcause mortality, still, the best predictor of outcome found (LAEF representing LA reservoir function)…”

Section: Discussionmentioning

confidence: 99%

Left Atrial Functional Assessment and Mortality in Patients with Severe Aortic Stenosis

et al. 2020

Preprint

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Background: Aortic valve stenosis (AS) is the most common primary valvular heart disease leading to surgical or percutaneous aortic valve replacement (AVR) in Europe and its prevalence is growing. While other risk factors in severe AS are well documented, less is known about the association between left atrial (LA) function and prognosis in AS. Our aim is to clarify the relationship between LA function measured at severe AS diagnosis (evaluated by means of volumetric assessment) and all-cause mortality during follow-up.Methods: We retrospectively evaluated patients diagnosed with severe AS for the first time at our echocardiography laboratory. We evaluated LA reservoir, conduit and pump function by measuring LA volumes at different timings of cardiac cycle. Treatment strategy was decided according to heart team consensus and patient decision. We divided patients into groups according to terciles of LA reservoir, conduit and pump function. Primary outcome was defined by the occurrence of all-cause mortality during follow-up.Results: A total of 451 patients were included in the analysis, with a median follow-up time of 73 months (interquartile range 44.5). 55.8% of patients underwent AVR and 45.5% of patients registered the primary outcome during follow-up. Left atrial emptying fraction (LAEF) was the best LA functional parameter and the best overall parameter in discriminating primary outcome (AUC 0.840, 95% CI 0.803-0.872, p<0.001). After adjustment for clinical, demographic and echocardiographic variables, cumulative survival of patients with LAEF <37% and LAEF 37 to 53% relative to patients with LAEF ≥54% remained significantly lower (hazard ratio 19.04, 95% CI 8.30-43.67, P<0.001 and hazard ratio 4.09, 95% CI 1.85-9.06, p=0.001, respectively). After adjustment for AVR, excess risk of LAEF <37% and LAEF 37 to 53% relative to LAEF ≥54% remained significant (hazard ratio 13.95, 95% CI 5.98-32.54, P<0.001 and hazard ratio 3.97, 95% CI 1.80-8.78, P=0.001, respectively).Conclusions: In patients with a first diagnosis of severe AS, LA function, evaluated by means of volumetric assessment, is an independent predictor of all-cause mortality and a more potent predictor of death compared to classical severity parameters. These data can be useful to identify high-risk patients who might benefit of AVR.