Risk stratification in asymptomatic moderate to severe aortic stenosis: the importance of the valvular, arterial and ventricular interplay

Abstract

-up (mean, 20 (19) months), 11 patients developed symptoms but were not operated on, 57 required aortic valve replacement and six patients died. In multivariable Cox regression analysis, four parameters that were associated with the outcome were identified: peak aortic jet velocity, left ventricular systolic (LV) longitudinal deformation, valvulo-arterial impedance and indexed left atrial area. Using receiverÀoperator characteristic curve analysis, a peak aortic jet velocity $4.4 m/s, a LV longitudinal myocardial deformation #15.9%, a valvular-arterial impedance $4.9 mm Hg/ml per m 2 and an indexed left atrial area $12.2 cm

Impact of Mean Transaortic Pressure Gradient on Long‐Term Outcome in Patients With Severe Aortic Stenosis and Preserved Left Ventricular Ejection Fraction

“…Several studies have investigated the value of Vmax for risk stratification of patients with asymptomatic severe AS. In a study based on 163 asymptomatic patients with severe AS, Vmax >4.4 m/s was the best cutoff for the prediction of a composite end point, including onset of symptoms, AVR, and death 25. In this study,25 2‐year event‐free survival was 30% for patients with Vmax >4.4 m/s versus 60% for patients with Vmax <4.4 m/s.…”

Outcomes in Asymptomatic Severe Aortic Stenosis With Preserved Ejection Fraction Undergoing Rest and Treadmill Stress Echocardiography

“…In one prior study of 79 patients with severe asymptomatic AS it was demonstrated that LV‐GLS and Zva were both independently associated with survival at a mean of 23 months follow‐up 18. Also, in 2 other small prior studies totaling 222 asymptomatic patients with severe AS, it was demonstrated that Zva and LV‐GLS were both independently associated with a combined end point of AS symptoms, AVR, or death 17, 19. Despite similar findings in these 3 prior reports, each was limited by small sample size, lack of exercise testing data, and longer‐term follow‐up.…”

“…Therefore, objective and reproducible parameters that identify early LV dysfunction, before a drop in LVEF could potentially allow more appropriate timing of surgery and in turn, allow improved survival. Over the past decade, the relationship between global LV load and abnormal LV systolic performance in AS patients, even in those with preserved LVEF has become more apparent, and the use of novel echocardiographic measures of LV load (Zva)19, 20, 45 and LV systolic performance (LV‐GLS)18, 30, 46 have been proposed as potential markers of early dysfunction, providing incremental prognostic utility.…”

“…A cutoff ≥35 mL/m 2 was considered as preserved LV‐SVI 27, 28, 29. Additionally, Zva was measured using the following formula: (systolic arterial pressure, measured at the time of echocardiography+mean aortic valve pressure gradient)/LV‐SVI 19, 21, 22…”

“…In addition, exercise‐induced drop in systolic blood pressure is a Class IIa indication for surgery1, 2 However, these recommendations are based upon multiple small reports with heterogeneous end points3, 9, 10, 11, 12, 13, 14, 15 In a recent study, we have demonstrated that in asymptomatic patients with severe AS and preserved left ventricular ejection fraction (LVEF), only 50% achieved 100% of age‐sex predicted exercise capacity; with exercise stress testing providing significant reclassification of longer‐term mortality risk16 In the past decade, novel echo parameters including reduced left ventricular global longitudinal strain (LV‐GLS)17, 18, 19 and valvuloarterial impedance (Zva)17, 19, 20 have also been associated with worse prognosis in patients with asymptomatic severe AS. However, no study has systematically evaluated the incremental prognostic impact of resting Zva and LV‐GLS on data obtained from exercise stress testing in patients with asymptomatic severe AS and preserved LVEF.…”