Surgical aortic valve replacement for low-gradient aortic stenosis

Abstract

AimsLow-gradient aortic stenosis is a challenging entity that needs accurate preoperative evaluation. For this high-risk patient population, ad hoc predictive scores are not available and profile risk is currently revealed by the EuroSCOREs. Aims of this study are to verify the suitability of the ES II as predictor of mortality in low-gradient aortic stenosis and to analyse the role of surgery as a treatment.MethodsFrom June 2013 to August 2019, 414 patients underwent surgical aortic valve replacement for low-gradient aortic stenosis. Mean age was 75.78 ± 6.77 years and 190 were women. The prognostic value of Logistic EuroSCORE and EuroSCORE II were compared by receiver-operating characteristics (ROC) curve analysis.ResultsIn-hospital, 30-day and 1-year mortality rates were respectively 3.4, 2.9 and 4.8% (14, 12 and 20 patients over 414). In-hospital mortality risk calculated by the Additive EuroSCORE was 7.2 ± 2.7%, by the Logistic EuroSCORE was 9 ± 5.2% and by the ES II was 4.13 ± 2.56%. The prognostic values of the EuroSCORE II and of the EuroSCORE were analysed in a ROC curve analysis for the prediction of in-hospital mortality [area under the curve (AUC): 0.62 vs. 0.58], 30-day mortality (AUC: 0.63 vs. 0.64) and 1-year mortality (AUC: 0.79 vs. 0.65). Both scores did not show significant differences with the only exception of 1-year mortality, for which EuroSCORE II had a better predictive ability than the Logistic EuroSCORE (P < 0.05).ConclusionIn low-gradient aortic stenosis undergoing surgery, the EuroSCORE II is a strong predictor of 1-year mortality.

Diastolic dysfunction and clinical outcomes after transcatheter or surgical aortic valve replacement in patients with atypical aortic valve stenosis

“…Several studies have suggested that patients with atypical aortic stenosis are a higher-risk cohort of patients hampered by an increased risk of adverse cardiovascular events. 24,25 Indeed, Saito et al 25 illustrated that diastolic dysfunction was highly prevalent in patients with severe aortic stenosis undergoing TAVR. They found that patients with increasing grades of diastolic dysfunction had higher rates of all-cause mortality at 1 year, mainly because of higher rates of cardiovascular death.…”

“…Furthermore, the role that diastolic dysfunction has in the adverse outcomes in patients with atypical aortic stenosis according to AVR modality was unknown. Several studies have suggested that patients with atypical aortic stenosis are a higher-risk cohort of patients hampered by an increased risk of adverse cardiovascular events 24,25 . Indeed, Saito et al 25 reported that patients with pLFLG aortic stenosis who undergo TAVR had increased all-cause mortality, more prevalent clinical heart failure, and more frequent hospitalizations for valve-related symptoms than patients with typical, normal-flow high-gradient (typical) aortic stenosis.…”

Prognostic value of coronary microvascular dysfunction in patients with aortic stenosis and nonobstructed coronary arteries

“…Several studies have suggested LV remodelling, particularly myocardial fibrosis, with adverse cardiac outcomes in aortic valve stenosis. 45,46 Pathological changes in CMD are perimyocytic fibrosis and a reduction in the counts of resistance vessels per unit of weight. 47 As a result, CMD could play a role in the pathophysiology of aortic valve stenosis, participating in the development of myocardial fibrosis and impairment of left ventricular function.…”

“…Although it is still undetermined whether CMD is a cause or consequence of underlying myocardial disease in aortic valve stenosis, 34 the prognostic significance of CMD in patients with aortic valve stenosis has been demonstrated in our study as well as in prior studies mentioned above; if identified in a timely way, this could help in risk stratification of at-risk patients and improve their outcomes and may guide the best time for AVR. Several studies have suggested LV remodelling, particularly myocardial fibrosis, with adverse cardiac outcomes in aortic valve stenosis 45,46 . Pathological changes in CMD are perimyocytic fibrosis and a reduction in the counts of resistance vessels per unit of weight 47 .…”