Impact of Surgical and Transcatheter Aortic Valve Replacement in Low-Gradient Aortic Stenosis

Ueyama, Hiroki; Kuno, Toshiki; Harrington, Michael; Takagi, Hisato; Krishnamoorthy, Parasuram; Sharma, Samin K.; Kini, Annapoorna

doi:10.1016/j.jcin.2021.04.038

Cited by 27 publications

(9 citation statements)

References 52 publications

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“…The same finding was reported by a sub-analysis of the PARTNER trial, where, after a small early hazard associated with SAVR in the first 30 days, both TAVR and SAVR similarly improved outcome with respect to medical therapy alone (13). These results have been further confirmed by a recent meta-analysis, showing that aortic valve replacement was associated with a significant decrease in allcause mortality regardless of surgical or transcatheter approach and in all subclasses of LG AS (38).…”

Section: Discussionsupporting

confidence: 78%

Early and mid-term outcome of patients with low-flow–low-gradient aortic stenosis treated with newer-generation transcatheter aortic valves

Fraccaro

Tarantini²,

Rosato³

et al. 2022

Front. Cardiovasc. Med.

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Patients with non-paradoxical low-flow–low-gradient (LFLG) aortic stenosis (AS) are at increased surgical risk, and thus, they may particularly benefit from transcatheter aortic valve replacement (TAVR). However, data on this issue are still limited and based on the results with older-generation transcatheter heart valves (THVs). The aim of this study was to investigate early and mid-term outcome of TAVR with newer-generation THVs in the setting of LFLG AS. Data for the present analysis were gathered from the OBSERVANT II dataset, a national Italian observational, prospective, multicenter cohort study that enrolled 2,989 consecutive AS patients who underwent TAVR at 30 Italian centers between December 2016 and September 2018, using newer-generation THVs. Overall, 420 patients with LVEF ≤50% and mean aortic gradient <40 mmHg were included in this analysis. The primary outcomes were 1-year all-cause mortality and a combined endpoint including all-cause mortality and hospital readmission due to congestive heart failure (CHF) at 1 year. A risk-adjusted analysis was performed to compare the outcome of LFLG AS patients treated with TAVR (n = 389) with those who underwent surgical aortic valve replacement (SAVR, n = 401) from the OBSERVANT I study. Patients with LFLG AS undergoing TAVR were old (mean age, 80.8 ± 6.7 years) and with increased operative risk (mean EuroSCORE II, 11.5 ± 10.2%). VARC-3 device success was 83.3% with 7.6% of moderate/severe paravalvular leak. Thirty-day mortality was 3.1%. One-year all-cause mortality was 17.4%, and the composite endpoint was 34.8%. Chronic obstructive pulmonary disease (HR 1.78) and EuroSCORE II (HR 1.02) were independent predictors of 1-year mortality, while diabetes (HR 1.53) and class NYHA IV (HR 2.38) were independent predictors of 1-year mortality or CHF. Compared with LFLG AS treated with SAVR, TAVR patients had a higher rate of major vascular complications and permanent pacemaker, while SAVR patients underwent more frequently to blood transfusion, cardiogenic shock, AKI, and MI. However, 30-day and 1-year outcomes were similar between groups. Patients with non-paradoxical LFLG AS treated by TAVR were older and with higher surgical risk compared with SAVR patients. Notwithstanding, TAVR was safe and effective with a similar outcome to SAVR at both early and mid-term.

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Section: Discussionsupporting

confidence: 78%

Early and mid-term outcome of patients with low-flow–low-gradient aortic stenosis treated with newer-generation transcatheter aortic valves

Fraccaro

Tarantini²,

Rosato³

et al. 2022

Front. Cardiovasc. Med.

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“…Transcatheter aortic valve replacement (TAVR) is an attractive alternative due to its less invasive profile. It is associated with good short-term outcomes in LFLG-AS patients, however with a high 2-year mortality ( 23 ). There is a lack of prospective studies comparing surgical and TAVR in LFLG-AS, hindering prognostic stratification and risk assessment.…”

Section: Discussionmentioning

confidence: 99%

Multimodality imaging methods and systemic biomarkers in classical low-flow low-gradient aortic stenosis: Key findings for risk stratification

Lopes

Campos

Rosa

et al. 2023

Front. Cardiovasc. Med.

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ObjectivesThe aim of the present study is to assess multimodality imaging findings according to systemic biomarkers, high-sensitivity troponin I (hsTnI) and B-type natriuretic peptide (BNP) levels, in low-flow, low-gradient aortic stenosis (LFLG-AS).BackgroundElevated levels of BNP and hsTnI have been related with poor prognosis in patients with LFLG-AS.MethodsProspective study with LFLG-AS patients that underwent hsTnI, BNP, coronary angiography, cardiac magnetic resonance (CMR) with T1 mapping, echocardiogram and dobutamine stress echocardiogram. Patients were divided into 3 groups according to BNP and hsTnI levels: Group 1 (n = 17) when BNP and hsTnI levels were below median [BNP < 1.98 fold upper reference limit (URL) and hsTnI < 1.8 fold URL]; Group 2 (n = 14) when BNP or hsTnI were higher than median; and Group 3 (n = 18) when both hsTnI and BNP were higher than median.Results49 patients included in 3 groups. Clinical characteristics (including risk scores) were similar among groups. Group 3 patients had lower valvuloarterial impedance (P = 0.03) and lower left ventricular ejection fraction (P = 0.02) by echocardiogram. CMR identified a progressive increase of right and left ventricular chamber from Group 1 to Group 3, and worsening of left ventricular ejection fraction (EF) (40 [31–47] vs. 32 [29–41] vs. 26 [19–33]%; p < 0.01) and right ventricular EF (62 [53–69] vs. 51 [35–63] vs. 30 [24–46]%; p < 0.01). Besides, there was a marked increase in myocardial fibrosis assessed by extracellular volume fraction (ECV) (28.4 [24.8–30.7] vs. 28.2 [26.9–34.5] vs. 31.8 [28.9–35.5]%; p = 0.03) and indexed ECV (iECV) (28.7 [21.2–39.1] vs. 28.8 [25.4–39.9] vs. 44.2 [36.4–51.2] ml/m2, respectively; p < 0.01) from Group 1 to Group 3.ConclusionsHigher levels of BNP and hsTnI in LFLG-AS patients are associated with worse multi-modality evidence of cardiac remodeling and fibrosis.

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“…For patients with normal-flow, low-gradient AS, the European guidelines suggest that the stenosis is unlikely to be severe; however, several studies and meta-analyses have shown that a substantial proportion of these patients actually have true-severe AS and may benefit from AVR. 10 , 11 In symptomatic patients with normal-flow, low-gradient AS, it may therefore also be useful to perform a CT calcium score to confirm the severity of the stenosis and the need for AVR. The third step in the management of low-gradient AS is to determine the optimal type of AVR.…”

Section: Management Of Low-flow Low-gradient Asmentioning

confidence: 99%

Discordant Low-Gradient Aortic Stenosis: Assessing the Valve and the Myocardium

Pibarot

2024

Texas Heart Institute Journal

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Impact of Surgical and Transcatheter Aortic Valve Replacement in Low-Gradient Aortic Stenosis

Cited by 27 publications

References 52 publications

Early and mid-term outcome of patients with low-flow–low-gradient aortic stenosis treated with newer-generation transcatheter aortic valves

Early and mid-term outcome of patients with low-flow–low-gradient aortic stenosis treated with newer-generation transcatheter aortic valves

Multimodality imaging methods and systemic biomarkers in classical low-flow low-gradient aortic stenosis: Key findings for risk stratification

Discordant Low-Gradient Aortic Stenosis: Assessing the Valve and the Myocardium

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