Valvuloarterial impedance does not improve risk stratification in low-ejection fraction, low-gradient aortic stenosis: results from a multicentre study

Lévy, F.; Monin, Jean Luc; Ruşinaru, Dan; Petit‐Eisenmann, Hélène; Lelguen, C; Chauvel, Christophe; Adams, Catherine; Metz, Damien; Leleu, François; Guéret, Pascal; Tribouilloy, Christophe

doi:10.1093/ejechocard/jer022

Cited by 28 publications

(16 citation statements)

References 18 publications

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“…Similar to our study, except for the EF criteria, Levy et al investigated the prognostic significance of Zva in 184 patients who had severe AS with decreased LVEF, and concluded that Zva did not have a prognostic role after AVR,8 which supports the results of our study, although the targeted patients had different characteristics. Another study by Jander et al 13 reported that patients with ‘low gradient’ severe AS despite preserved EF, who likely have high Zva,3 4 have a prognosis similar to patients with moderate AS in comparison to ‘high gradient’ severe AS, which suggests that prognosis may be mostly impacted by ‘valvular load’ rather than ‘arterial load’.…”

Section: Discussionsupporting

confidence: 91%

“…However, it is unclear whether Zva retains its prognostic impact on survival after conventional aortic valve replacement (AVR), given continued excess of afterload in some patients 8. We hypothesised that patients with severe AS with preserved ejection fraction (EF) who have increased Zva have poorer prognosis even after successful AVR because of high-global haemodynamic load chronically causing LV myocardial structural damage and thus, the recovery of LV function and regression of LV hypertrophy is slower or irreversible.…”

Section: Introductionmentioning

confidence: 99%

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Does valvuloarterial impedance impact prognosis after surgery for severe aortic stenosis in the elderly?

et al. 2015

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BackgroundValvuloarterial impedance (Zva) was introduced as a prognostic measure in patients with aortic stenosis (AS). However, it is unclear whether Zva has a prognostic impact on survival after surgical aortic valve replacement (AVR) in patients with severe AS with preserved ejection fraction (EF).MethodsWe retrospectively reviewed 929 consecutive patients who had AVR. We investigated 170 elderly patients (age >65 years, mean 76 years) who had AVR secondary to severe AS (mean gradient ≥40 mm Hg; aortic valve area ≤1 cm2; peak velocity ≥4 m/s). Patients with EF <50%, greater than moderate aortic regurgitation, prior heart surgery and concomitant mitral or tricuspid valve surgery were excluded. Zva was calculated and the patients were divided into two groups; low Zva, Zva <4.3 (n=82) and high Zva, Zva ≥4.3 (n=88). The end point was all-cause of death. Survival curves were calculated according to Kaplan-Meier method.ResultsAge, prevalence of hypertension, diabetes, chronic kidney disease (CKD), atrial fibrillation, symptoms, EF, E/e′ and concomitant coronary artery bypass graft were not different between the groups. Survival was not different between the groups at 5 years (70% in low Zva and 81% in high Zva; p=0.21) and for the entire follow-up period (p=0.23). Only age was a significant factor in predicting survival by multivariate analyses in Cox proportional hazards model after adjusting for Zva, CKD, atrial fibrillation and hypertension.ConclusionsOur results suggest that preoperative Zva does not have a prognostic impact on postoperative survival in elderly patients with severe AS with preserved EF. Further investigation is needed to elucidate the controversial results.

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Section: Discussionsupporting

confidence: 91%

Section: Introductionmentioning

confidence: 99%

Does valvuloarterial impedance impact prognosis after surgery for severe aortic stenosis in the elderly?

et al. 2015

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“…The left ventricle, ejecting blood through a stenotic valve, needs to work against the arterial load as well . Previous study have demonstrated that a higher Zva in the context of AS was consistent with poorer survival outcomes . We found that patients who switched from low‐flow to normal‐flow AS were associated with significant reduction in Zva, although the aortic valve area and transaortic pressure indices remained similar.…”

Section: Discussionmentioning

confidence: 46%

Predicting changes in flow category in patients with severe aortic stenosis and preserved left ventricular ejection fraction on medical therapy

et al. 2017

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Background/Objectives Controversy surrounds the prognosis and management of patients with paradoxical low‐flow severe aortic stenosis (AS) with preserved left ventricular ejection fraction (LVEF). It was not certain if patients in a particular flow category remained in the same category as disease progressed. We investigated whether there were switches in categories and if so, their predictors. Methods Consecutive subjects (n = 203) with isolated severe AS and paired echocardiography (>180 days apart) were studied. They were divided into 4 groups, based on their flow categories and if they progressed on subsequent echocardiography to switch or remain in the same flow category. Univariate analyses of clinical and echocardiographic parameters identified predictors of these changes in flow category. Results One hundred eighteen were normal flow (SVI ≥ 35 mL/m2), while 85 were low flow on index echocardiography. In the patients with normal flow, 33% switched to low flow. This was associated with higher valvuloarterial impedance (Zva, P < .001) and lower systemic arterial compliance (SAC, P < .001) compared to index echocardiography, and predicted by higher initial Zva (optimized cutoff >4.77 mm Hg/mL/m2, AUC = 0.81 [95% CI:0.75–0.87, P < .001]). In patients with low flow, 25% switched to normal flow, which was associated with lower Zva and higher SAC and the switch was predicted by a higher initial mean transaortic pressure gradient. Conclusions A significant number of patients switched flow categories in severe AS with preserved LVEF on subsequent echocardiography. Changes in flow were reflected by respective changes in Zva and SAC. Identifying echocardiographic predictors of a switch in category may guide prognostication and management of such patients.

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“…This may have been due to the perception that low‐flow AS was less severe or that the prognostic implications of surgery were unclear in this subgroup. Furthermore, caution must be taken that conventional parameters of AS severity in previous study (eg, valvuloarterial impedance, aortic valve resistance, stroke work loss, systemic arterial compliance) may not be reliable in low‐flow . While otherwise useful, these conventional parameters may underestimate severity in low‐flow AS as the effect of afterload appears more significant in the low‐flow state .…”

Section: Discussionmentioning

confidence: 99%

Comparing characteristics and clinical and echocardiographic outcomes in low‐flow vs normal‐flow severe aortic stenosis with preserved ejection fraction in an Asian population

et al. 2017

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Background/Objectives In severe aortic stenosis (AS), deterioration of left ventricular ejection fraction (LVEF) to <50% is an AHA/ACC class I indication for valve replacement, regardless of symptoms. Controversy surrounds prognosis of low‐flow AS compared to normal‐flow, and no study has examined LVEF deterioration. We compared factors associated with LVEF deterioration (to <50%) and clinical outcomes. Methods Consecutive subjects with low‐flow (stroke volume index <35 mL/m2, n=56) and normal‐flow (n=72) severe AS (aortic valve area <1 cm2) with preserved LVEF (>50%) and with paired echocardiography were studied. Univariate and multivariate analyses identified factors associated with LVEF deterioration. Clinical outcomes were determined on follow‐up for more than 5 years. Results Significant LVEF deterioration (to <50%) was seen in 18% of low‐flow (initial LVEF 63±8% to 32±9%) and 18% of normal‐flow AS (61±7% to 31±12%). Independent factors in low‐flow AS were hypertension (OR: 30.7, 95% CI: 2.0–467.6, P=.014) and higher end‐systolic wall stress (OR: 1.086, 95% CI: 1.022–1.153, P=.008), compared to normal‐flow, which were hypertension (OR: 15.9, 95% CI: 3.1–81.9, P=.001), higher septal E/E′ ratio (OR: 1.16, 95% CI: 1.01–1.35, P=.043), lower septal S′ velocity (OR: 0.204, 95% CI: 0.061–0.682, P=.010), and higher end‐systolic wall stress (OR: 1.051, 95% CI: 1.001–1.104, P=.047). Overall, a third of the cohort experienced MACE, regardless of flow (log‐rank 0.048, P=.827). However, aortic valve replacement (AVR) rates were lower in low‐flow AS (20% vs 43%, P=.005). Conclusions Low‐flow AS despite normal LVEF appears similar to normal‐flow in terms of LVEF deterioration and clinical outcomes in our Asian population. AVR rate was lower even though low‐flow may not reflect less severe disease.

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Valvuloarterial impedance does not improve risk stratification in low-ejection fraction, low-gradient aortic stenosis: results from a multicentre study

Abstract: Increased Zva is related to low LVEF and more frequent CR on DSE in LEF/LGAS. However, Zva did not allow an accurate distinction between true and pseudo-severe AS and failed to predict operative and long-term mortality after aortic valve replacement, in LEF/LGAS.

Cited by 28 publications

References 18 publications

Does valvuloarterial impedance impact prognosis after surgery for severe aortic stenosis in the elderly?

Does valvuloarterial impedance impact prognosis after surgery for severe aortic stenosis in the elderly?

Predicting changes in flow category in patients with severe aortic stenosis and preserved left ventricular ejection fraction on medical therapy

Comparing characteristics and clinical and echocardiographic outcomes in low‐flow vs normal‐flow severe aortic stenosis with preserved ejection fraction in an Asian population

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