Prognostic Value of Aortic Valve Area Index in Asymptomatic Patients With Severe Aortic Stenosis

Saitô, Toshio; Muro, Takashi; Takeda, Hiromi; Hyodo, Eiichi; Ehara, Shoichi; Nakamura, Yasuhiro; Hanatani, Akihisa; Shimada, Kenei; Yoshiyama, Minoru

doi:10.1016/j.amjcard.2012.02.056

Cited by 48 publications

(27 citation statements)

References 19 publications

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“…Indexation has been recommended specifically in very small patients with a BSA<1.5 m 2 or a BMI<22 4 5. In our study patients with a BSA<1.5 m 2 were classified with severe stenosis in 95% before and 85% after indexation in the retrospective cohort (n=91, p<0.04) and in 47% vs 37% in SEAS (n=19, p=0.34).…”

Section: Resultsmentioning

confidence: 87%

“…Similarly, the increase in patients with severe stenosis seen with indexation was markedly more pronounced in males than in females, possibly due to smaller body size in the latter. Interestingly, in a recent retrospective Japanese study in 103 comparatively small asymptomatic patients with mean BSA of 1.5±0.2 m 2 , an AVA index of ≥0.6 cm 2 /m 2 was frequently observed in patients with an AVA<1.0 cm 2, 5 and an AVA index of <0.6 cm 2 /m 2 was predictive of a poor outcome.…”

Section: Discussionmentioning

confidence: 93%

“…However, clinical or outcome studies supporting this recommendation are rare 5. In theory, calculation of AVA index should not change the overall number of patients with severe stenosis in a given population but rather result in a decrease in the percentage of patients with the diagnosis of severe stenosis in smaller patients and an increase in larger patients.…”

Section: Introductionmentioning

confidence: 99%

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Indexing aortic valve area by body surface area increases the prevalence of severe aortic stenosis

Jander

Gohlke-Bärwolf

Bahlmann

et al. 2013

Heart

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Background To account for differences in body size in patients with aortic stenosis, aortic valve area (AVA) is divided by body surface area (BSA) to calculate indexed AVA (AVA index ). Cut-off values for severe stenosis are <1.0 cm 2 for AVA and <0.6 cm 2 /m 2 for AVA index . Objective To investigate the influence of indexation on the prevalence of severe aortic stenosis and on the predictive accuracy regarding clinical outcome. Methods Echocardiographic and anthropometric data from a retrospective cohort of 2843 patients with aortic stenosis ( jet velocity >2.5 m/s) and from 1525 patients prospectively followed in the simvastatin and ezetimibe in aortic stenosis (SEAS) trial were analysed. Results The prevalence of severe stenosis increased with the AVA index criterion compared to AVA from 71% to 80% in the retrospective cohort, and from 29% to 44% in SEAS (both p<0.001). Overall, the predictive accuracy for aortic valve events was virtually identical for AVA and AVA index in the SEAS population (mean follow-up of 46 months; area under the receiver operating characteristic curve: 0.67 (95% CI 0.64 to 0.70) vs 0.68 (CI 0.65 to 0.71) (NS). However, 213 patients additionally categorised as severe by AVA index experienced significantly less valve related events than those fulfilling only the AVA criterion ( p<0.001). Conclusions Indexing AVA by BSA (AVA index ) significantly increases the prevalence of patients with criteria for severe stenosis by including patients with a milder degree of the disease without improving the predictive accuracy for aortic valve related events.

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Section: Resultsmentioning

confidence: 87%

Section: Discussionmentioning

confidence: 93%

Section: Introductionmentioning

confidence: 99%

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Indexing aortic valve area by body surface area increases the prevalence of severe aortic stenosis

Jander

Gohlke-Bärwolf

Bahlmann

et al. 2013

Heart

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“…6,23 Although contemporary outcome data supporting the prognostic value of AVA/BSA are scant, 9,24 US and European guidelines 1,2 have included AVA/BSA among criteria for grading AS severity (ie, AVA/BSA <0.6 cm 2 /m 2 ). In a study including 103 asymptomatic patients with, AS, AVA/BSA 24 Jander et al 9 have recently shown that among patients with AS the number of patients with AVA/BSA <0.6 cm 2 /m 2 is significantly greater than the number of patients with AVA <1 cm 2 and that the predictive accuracy for aortic valve events of the 2 parameters is almost identical. 9 Our results show that asymptomatic patients with AS in whom at the time of diagnosis AVA/BSA is <0.4 cm 2 /m 2 represent a high-risk group with >60% rate of events at 2 years.…”

Section: Discussionmentioning

confidence: 99%

Outcome Implication of Aortic Valve Area Normalized to Body Size in Asymptomatic Aortic Stenosis

Tribouilloy

Bohbot

Maréchaux

et al. 2016

Circ: Cardiovascular Imaging

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Background— Current guidelines define severe aortic stenosis in patients with aortic valve area normalized to body surface area (AVA/BSA) <0.6 cm 2 /m 2 ; yet, this cutoff has never been validated. Moreover, it is not known whether AVA normalization to other body size indexes allows improved outcome prediction. We aim to test the value of AVA normalized to body size for outcome prediction in asymptomatic aortic stenosis. Methods and Results— We included 289 patients with asymptomatic aortic stenosis, preserved ejection fraction, and AVA<1.3 cm 2 at diagnosis. The outcome measure was the occurrence of aortic valve replacement or all-cause death or during follow-up. AVA was normalized to BSA, height, weight, and body mass index. For each normalized index, patients in the lowest tertile were at high risk of events whereas outcome was similar for the other tertiles. High risk of events was observed with AVA/BSA <0.4 cm 2 /m 2 (adjusted hazard ratio [HR], 3.42 [2.09–5.60]), AVA/height <0.45 cm 2 /m (adjusted HR, 3.99 [2.42–6.60]), AVA/weight <0.01 cm 2 /kg (adjusted HR, 3.37 [2.07–5.49]), and AVA/body mass index <0.029 cm 2 /kg per meter square (adjusted HR, 3.23 [1.99–5.24]). Mortality risk was high with AVA/height <0.45 cm 2 /m (adjusted HR, 2.18 [1.28–3.71]), followed by AVA/BSA <0.40 cm 2 /m 2 (adjusted HR, 1.84 [1.09–3.11]), AVA/weight <0.01 cm 2 /kg (adjusted HR, 1.78 [1.07–2.98]), and AVA/body mass index <0.029 cm 2 /kg per meter square (adjusted HR, 1.75 [1.04–2.93]). AVA/height showed better predictive performance than AVA/BSA with improved reclassification and better discrimination (net reclassification improvement: 0.33 versus 0.28; integrated discrimination improvement: 0.10 versus 0.08; C statistic: 0.67 versus 0.65), whereas AVA/weight and AVA/body mass index showed lower predictive capacity. Conclusions— Among AVA normalization methods, AVA/height <0.45 cm 2 /m followed by AVA/BSA <0.40 cm 2 /m 2 seem as robust parameters for defining high risk in asymptomatic aortic stenosis. The prognostic value of AVA/height deserves future research.

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“…An AVAi G0.6 cm 2 /m 2 has been proposed to identify severe AS, as per the most recent guidelines [1••, 2, 3]. However, there is sparse prognostic data to support this approach [23]. In fact, correcting AVA using a simple linear relationship with body surface area actually increases the prevalence of discordant hemodynamic data, and AVAi was not superior to AVA Fig.…”

Section: Impact Of Body Sizementioning

confidence: 95%

Low Gradient Aortic Stenosis

Doucet

Burwash

2015

Curr Treat Options Cardio Med

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Severe low-gradient (LG) aortic stenosis (AS) [aortic valve area (AVA) ≤ 1.0 cm(2), mean pressure gradient (MG) < 40 mmHg] represents a frequently encountered and challenging clinical dilemma. A systematic approach, which often requires several imaging modalities, should be undertaken to confirm the hemodynamic findings and rule out measurement error. Low-flow conditions often account for the discrepancy and can be present whether the left ventricular ejection fraction (LVEF) is depressed or normal. In patients with classical low-flow (LF), LG AS in which LVEF is reduced (<40-50 %), dobutamine stress echocardiography (DSE) should be used to distinguish patients with true severe AS and pseudo-severe AS, as well as to evaluate for the presence of left ventricular contractile or flow reserve. Surgical or transcatheter aortic valve replacement (AVR) should likely be reserved for those patients with true severe AS. Patient outcome with medical or surgical management generally relates to patient functional capacity, stenosis severity, and left ventricular functional reserve. Patients with severe LG AS with preserved LVEF can have a stroke volume that is either normal (>35 mL/m(2)) or low (<35 mL/m(2)). New data suggest that DSE can identify pseudo-severe AS in up to 30 % of patients with severe LF-LG AS with preserved LVEF. AVR should likely be restricted to those patients with true severe AS, although there is currently little data to support this strategy. Symptomatic patients with severe LG AS with preserved LVEF, whether they have normal or low flow, should be offered AVR. Transcatheter AVR provides an alternative therapeutic option in the high-risk patient.

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Prognostic Value of Aortic Valve Area Index in Asymptomatic Patients With Severe Aortic Stenosis

Cited by 48 publications

References 19 publications

Indexing aortic valve area by body surface area increases the prevalence of severe aortic stenosis

Indexing aortic valve area by body surface area increases the prevalence of severe aortic stenosis

Outcome Implication of Aortic Valve Area Normalized to Body Size in Asymptomatic Aortic Stenosis

Low Gradient Aortic Stenosis

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