Características y predictores ecocardiográficos de mortalidad en pacientes intervenidos con TAVI. La importancia de anticiparse al daño cardíaco global / Predictors of late mortality after TAVI: the relevance of early intervention to prevent global deterioration of cardiac function

Introducción: En nuestro medio, el implante percutáneo de prótesis aórtica (TAVI) se encuentra limitado a pacientes más añosos o de mayor riesgo quirúrgico, en quienes frecuentemente se retarda la intervención hasta que presenten signos avanzados de enfermedad. Objetivo: Evaluar el grado de compromiso miocárdico en pacientes sometidos a TAVI y determinar si la magnitud de este compromiso predice los resultados alejados del procedimiento. Métodos: Registro de pacientes sometidos a TAVI en 2 instituciones de Chile. Según la clasificación propuesta por Genereux el año 2017, se clasificaron desde el punto de vista ecocardiográfico como: 1) compromiso de ventrículo izquierdo; 2) compromiso de aurícula izquierda; 3) hipertensión pulmonar / insuficiencia tricuspídea significativa y 4) disfunción de ventrículo derecho. Resultados: Se incluyeron 209 pacientes. Se logró un procedimiento exitoso en 98,6%, registrándose una mortalidad intrahospitalaria de 2,9%. El compromiso cardíaco se extendió más allá de las cavidades izquierdas en 24,7% de los casos (estadíos 3 y 4). A una mediana de seguimiento de 650 días se registró una mortalidad de 26,8%. El compromiso de cavidades derechas (estadíos 3 y 4) se asoció a una mayor mortalidad (39,6% vs 22,1%, log rank p=0,015). En análisis multivariado, este compromiso fue el único factor que de forma independiente predijo mortalidad (HR 1,87, IC 1,01-3,44, p=0,044). Conclusiones: El compromiso de cavidades derechas se asocia a una mayor mortalidad alejada en pacientes sometidos a TAVI. Estos resultados debiesen estimular una derivación precoz de estos pacientes que, aunque añosos y de alto riesgo, tienen buenos resultados intervenidos precozmente.

Background: Locally, Transcatheter Aortic Valve Implantation (TAVI) is limited to very old or high-risk patients, whose intervention is frequently delayed until they develop signs of advanced disease. Aim: To evaluate the degree of myocardial compromise in patients undergoing TAVI and to determine whether the level of this compromise can predict results during follow-up. Methods: Registry of TAVI patients from 2 institutions in Chile. According to the classification proposed by Genereux in 2017, patients were classified based on the echocardiogram as 1) left ventricular compromise; 2) left atrial compromise; 3) pulmonary hypertension / severe tricuspid regurgitation; 4) right ventricular dysfunction. Results: The study included 209 patients. A successful procedure was achieved in 98.6% of cases, with an in-hospital mortality of 2.9%. Cardiac compromise extended beyond left chambers in 24.7% of cases (stages 3 and 4). During follow-up (median of 650 days) mortality was 26.8%. Right chambers involvement (stages 3 and 4) was associated with increased mortality (39.6% vs 22.1%, log rank p=0.015). In multivariate analysis, this compromise was the only factor that independently predicted mortality (HR 1.87, IC 1.01-3.44, p=0,044). Conclusions: Right chambers involvement was associated to increased mortality during follow-up of patients undergoing TAVI. These results should stimulate earlier referral of these high risk and older patients in order to obtain better results following the intervention.

Impact of the recovery of left ventricular ejection fraction after TAVI on mortality in patients with aortic stenosis.

OBJECTIVE: To assess the effects of transvalvular aortic valve implantation (TAVI) on the outcomes of the patients with symptomatic severe aortic stenosis (AS), and predict the effect of left ventricular ejection fraction (LVEF) and cardiac structural recovery on mortality after the TAVI in patients with different stage of LV function. METHODS: Out of 191 patients, 151 consecutive patients in 3 centers were evaluated for outcome analysis. Patients were classified into 3 subgroups as AS with reduced ejection fraction (ASrEF) (LVEF <40%), AS with mildly reduced EF (ASmrEF) (LVEF 40-49%) and AS with preserved EF (ASpEF) (LVEF ≥50%). RESULTS: The mean follow-up period was 19.4±12.4 (up to 54) months. All-cause mortality was not different among all 3 groups. (p=0.901). In multivariate analysis, stroke volume index (SVI) (Exp(B): 0.039, 95% confidence interval [CI]: 0.011-0.013, p<0.001), baseline blood urea nitrogen (Exp(B): 1.022, 95% CI: 1.006-1.038, p=0.006), and percent LVEF change after TAVI (d-LVEF) (Exp(B): 0.046, 95% CI: 0.004-0.610, p=0.046) were the independent predictors for mortality after TAVI. The receiver operating characteristic curve analysis showed that the cutoff value of "≤10%" for d-LVEF had sensitivity of 50%, specificity of 75%, and an area under the curve of 0.72 in predicting mortality in patients with SVI <35 mL/m2. CONCLUSION: Improvement of LVEF after TAVI, which reflected the marked LV reverse remodeling, has an impact on the prediction of the survival in patients with AS, and this is more prominent in patients with low SVI.

Effect of the 2017 European Guidelines on Reclassification of Severe Aortic Stenosis and Its Influence on Management Decisions for Initially Asymptomatic Aortic Stenosis.

BACKGROUND: The 2017 European Society of Cardiology guidelines for valvular heart disease included changes in the definition of severe aortic stenosis (AS). We wanted to evaluate its influence on management decisions in asymptomatic patients with moderate-severe AS. METHODS: We reclassified the AS severity of the participants of the PRIMID-AS study (Prognostic Importance of Microvascular Dysfunction in Asymptomatic Patients With AS), using the 2017 guidelines, determined their risk of reaching a clinical end point (valve replacement for symptoms, hospitalization, or cardiovascular death) and evaluated the prognostic value of aortic valve calcium score and biomarkers. Patients underwent echocardiography, cardiac magnetic resonance imaging, exercise tolerance testing, and biomarker assessment. RESULTS: Of the 174 participants, 45% (56/124) classified as severe AS were reclassified as moderate AS. This reclassified group was similar to the original moderate group in clinical characteristics, gradients, calcium scores, and remodeling parameters. There were 47 primary end points (41 valve replacement, 1 death, and 5 hospitalizations-1 chest pain, 2 dyspnea, 1 heart failure, and 1 syncope) over 368±156 days follow-up. The severe and reclassified groups had a higher risk compared with moderate group (adjusted hazard ratio 4.95 [2.02-12.13] and 2.78 [1.07-7.22], respectively), with the reclassified group demonstrating an intermediate risk. A mean pressure gradient ≥31 mm Hg had a 7× higher risk of the primary end point in the reclassified group. Aortic valve calcium score was more prognostic in females and low valve area but not after adjusting for gradients. NT-proBNP (N-terminal pro-brain-type natriuretic peptide) and myocardial perfusion reserve were associated with the primary end point but not after adjusting for positive exercise tolerance testing. Troponin was associated with cardiovascular death or unplanned hospitalizations. CONCLUSIONS: Reclassification of asymptomatic severe AS into moderate AS was common using the European Society of Cardiology 2017 guidelines. This group had an intermediate risk of reaching the primary end point. Exercise testing, multimodality imaging, and lower mean pressure gradient threshold of 31 mm Hg may improve risk stratification. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01658345.

Clinically Important Misclassification of Aortic Valve Stenosis Severity Using Non-Invasive Techniques: Simultaneous Echocardiography and Cardiac Catheterization During Transcatheter Aortic Valve Implantation in Awake Patients.

BACKGROUND: Suitability for transcatheter aortic valve (AV) implantation (TAVI) is determined by using transthoracic echocardiography (TTE), although left-sided cardiac catheterization (LCC) provides directly measured pressure data. TAVI in awake patients permits simultaneous comparison of TTE and LCC under physiologically relevant left ventricular loading conditions. We hypothesized that clinically important discrepancies between TTE and LCC would be identified. METHODS AND RESULTS: TAVI was performed in 108 awake patients undergoing intra-procedural TTE and LCC between January 1, 2016 and December 31, 2016, based upon pre-procedure TTE data. Intra-procedural assessments simultaneously were performed before and after prosthesis implantation. Based upon mean trans-AV systolic ejection pressure gradient (MSEPG), AS was graded as: mild (<20 mm Hg; grade 1), moderate (20 - <40 mm Hg; grade 2), or severe (≥40 mm Hg; grade 3). In 79 of the 108 (73.1%) patients, intra-procedural TTE and LCC assessments were concordant. In 2 of the 108 (1.9%) patients, TTE overestimated AS severity by ≥1 grade. In 27 of the 108 (25.0%) patients, TTE underestimated AS severity by ≥1 grade. In total, AS severity reclassification occurred in 29 (26.9%) patients. Overall, TTE underestimated MSEPG by 8.9 ± 1.2 mm Hg (TTE MSEPG versus LCC MSEPG; P < .001). CONCLUSION: Current TTE criteria appear to frequently and importantly underestimate AS severity. Because decision-making regarding TAVI often exclusively is based upon TTE data, these findings suggest either a continued role for LCC in the diagnostic assessment of AS in patients who do not meet standard TTE criteria or lowering TTE cutoffs for TAVI.

Classification of aortic stenosis using conventional machine learning and deep learning methods based on multi-dimensional cardio-mechanical signals.

This paper introduces a study on the classification of aortic stenosis (AS) based on cardio-mechanical signals collected using non-invasive wearable inertial sensors. Measurements were taken from 21 AS patients and 13 non-AS subjects. A feature analysis framework utilizing Elastic Net was implemented to reduce the features generated by continuous wavelet transform (CWT). Performance comparisons were conducted among several machine learning (ML) algorithms, including decision tree, random forest, multi-layer perceptron neural network, and extreme gradient boosting. In addition, a two-dimensional convolutional neural network (2D-CNN) was developed using the CWT coefficients as images. The 2D-CNN was made with a custom-built architecture and a CNN based on Mobile Net via transfer learning. After the reduction of features by 95.47%, the results obtained report 0.87 on accuracy by decision tree, 0.96 by random forest, 0.91 by simple neural network, and 0.95 by XGBoost. Via the 2D-CNN framework, the transfer learning of Mobile Net shows an accuracy of 0.91, while the custom-constructed classifier reveals an accuracy of 0.89. Our results validate the effectiveness of the feature selection and classification framework. They also show a promising potential for the implementation of deep learning tools on the classification of AS.

Invasive Hemodynamic Staging Classification of Cardiac Damage in Patients With Aortic Stenosis Undergoing Valve Replacement.

BACKGROUND: An echocardiographic 5-stage classification of cardiac damage in aortic stenosis (AS) has been shown to provide prognostic information. We aimed to create an analogous classification based on invasive hemodynamics. METHODS: We studied 421 patients (age 75 ± 10 years, 59% men) with severe AS with complete invasive hemodynamics obtained before aortic valve replacement (AVR). Cardiac damage stages were defined as follows: stage 0, absence of any of the following criteria; stage 1, left-ventricular end-diastolic pressure >15 mm Hg; stage 2, mean pulmonary artery wedge pressure > 15 mm Hg; stage 3, pulmonary vascular resistance > 3 Wood units and/or systolic pulmonary artery pressure > 60 mm Hg; stage 4, mean right atrial pressure >15 mm Hg. Patients were hierarchically classified in a given stage (worst stage) if the criterion was met for that stage. RESULTS: Sixty-seven (16%) patients were classified as stage 0, 113 (27%) as stage 1, 151 (36%) as stage 2, 73 (17%) as stage 3, and 17 (4%) as stage 4. After a median (interquartile range) follow-up of 3.8 (2.7 to 5.2) years after AVR, mortality was highest in stage 4 (hazard ratio; 95% confidence interval: 6.17 (1.74-21.89) vs stage 0; P = 0.005 and stage 3 patients (hazard ratio; 95% confidence interval: 4.17 (1.39-12.49) vs stage 0; P = 0.01,whereas mortality did not differ between patients in stages 0 to 2. CONCLUSIONS: A staging system of cardiac damage based on invasive hemodynamic parameters in patients with severe AS undergoing AVR predicts mortality. Pulmonary vascular disease and high right-atrial pressure are the major drivers of mortality.

Echocardiographic Assessment of Aortic Stenosis under Sedation Underestimates Stenosis Severity.

BACKGROUND: Sedation can impact aortic stenosis (AS) classification, which depends on left ventricular ejection fraction (<≥ [less than or greater than and/or equal to] 50%), aortic valve area (AVA<≥ 1 cm2), mean pressure gradient (<≥ 40 mm Hg), peak velocity <≥ 400 cm/sec, and stroke volume index (SVI <≥35 mL/m2). We compared AS classification by transthoracic echo (TTE) during wakefulness versus sedation. METHODS: Immediately following a baseline TTE performed during wakefulness, another TTE was done during sedation delivered for a concomitant transesophageal study in 69 consecutive patients with AS (mean age 78 ± 7 years, 32 males). AVA was calculated through the continuity equation using the relevant hemodynamic parameters measured by each TTE study and same left ventricular outflow tract. AS class was defined as moderate, severe high gradient (HG), low ejection fraction low flow low gradient (LF-LG), paradoxical LF-LG (PLFLG), and normal flow low gradient (NF-LG). Based on conservative versus invasive treatment implication, AS classes were aggregated into group A (moderate AS and NFLG) and group B (HG, low-EF LF-LG, and PLFLG). RESULTS: During sedation, systolic and diastolic blood pressure decreased by 14.3 ± 29 and 8 ± 22 mm Hg, respectively, mean pressure gradient from 30.4 ± 10.9 to 27.2 ± 10.8 mm Hg, peak velocity from 345.3 ± 57.7 to 329.3 ± 64.8 cm/m2, and SVI from 41.5 ± 11.3 to 38.3 ± 11.8 mL/m2 (all P < .05). Calculated AVA was similar (delta = -0.009 ± 0.15 cm2). Individual discrepancies in hemodynamic parameters between the paired TTE studies resulted in an overall 17.4% rate of AS intergroup misclassification with sedation, with a relative risk of 1.09 of downgrade misclassification from group B to A versus upgrade misclassification (P < .001). CONCLUSIONS: Sedation TTE assessment downgrades AS severity in a significant proportion of patients, with a conversely smaller proportion of patients being upgraded, and therefore cannot be a substitute for wakefulness assessment.

Association of Structural and Functional Cardiac Changes With Transcatheter Aortic Valve Replacement Outcomes in Patients With Aortic Stenosis.

Importance: Severe aortic stenosis causes pressure overload of the left ventricle, resulting in progressive cardiac dysfunction that can extend beyond the left ventricle. A staging system for aortic stenosis has been recently proposed that quantifies the extent of structural and functional cardiac changes in aortic stenosis. Objectives: To confirm the reproducibility of a proposed staging system and expand the study findings by performing a survival analysis and to evaluate the association of aortic stenosis staging with both cardiac and noncardiac post-transcatheter aortic valve replacement (TAVR) readmissions. Design, Setting, and Participants: A cohort analysis was conducted involving patients with severe aortic stenosis who underwent TAVR at the University of Pittsburgh Medical Center between July 1, 2011, and January 31, 2017. Patients who had undergone TAVR for valve-in-valve procedures and had an incomplete or unavailable baseline echocardiogram study for review were excluded. Clinical, laboratorial, and procedural data were collected from the Society of Thoracic Surgeons database and augmented by electronic medical record review. Exposures: The aortic stenosis staging system is based on echocardiographic markers of abnormal cardiac function. The stages are as follows: stage 1 (left ventricle changes - increased left ventricular mass index; early mitral inflow to early diastolic mitral annulus velocity (E/e') >14; and left ventricular ejection fraction <50%), stage 2 (left atrial or mitral changes - left atrial volume index >34 mL/m2; moderate to severe mitral regurgitation; and atrial fibrillation), stage 3 (pulmonary artery or tricuspid changes - pulmonary artery systolic pressure ≥60 mm Hg; moderate to severe tricuspid regurgitation), and stage 4 (right ventricle changes - moderate to severe right ventricle dysfunction). Main Outcomes and Measures: Primary outcome was post-TAVR all-cause mortality. Secondary outcomes were composite outcomes of all-cause mortality and post-TAVR all-cause and cardiac-cause readmissions. Results: A total of 689 consecutive patients (351 [50.9%] were male, with a mean [SD] age of 82.4 [7.6] years) were included. The prevalence of stage 1 was 13%; stage 2, 62%; stage 3, 21%; and stage 4, 4%. Patients with higher staging had a greater burden of comorbidities as captured by the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM). Despite adjustment for STS-PROM, a graded association was found between aortic stenosis staging and all-cause mortality (hazard ratio [HR] stage 2 vs stage 1: 1.37 [95% CI, 0.81-2.31; P = .25]; stage 3 vs stage 1: 2.24 [95% CI, 1.28-3.92; P = .005]; and stage 4 vs stage 1: 2.83 [95% CI, 1.39-5.76; P = .004]). Stage 3 patients had higher post-TAVR readmission rates for both cardiac (HR, 1.84; 95% CI, 1.13-3.00; P = .01) and noncardiac causes. Conclusions and Relevance: Aortic stenosis staging appears to show a strong graded association between the extent of cardiac changes and post-TAVR all-cause mortality; such staging may improve patient care, risk stratification, assessment of prognosis, and shared decision making for patients undergoing TAVR.

A novel, data-driven conceptualization for critical left heart obstruction.

BACKGROUND: Qualitative features of aortic and mitral valvar pathology have traditionally been used to classify congenital cardiac anomalies for which the left heart structures are unable to sustain adequate systemic cardiac output. We aimed to determine if novel groups of patients with greater clinical relevance could be defined within this population of patients with critical left heart obstruction (CLHO) using a data-driven approach based on both qualitative and quantitative echocardiographic measures. METHODS: An independent standardized review of recordings from pre-intervention transthoracic echocardiograms for 651 neonates with CLHO was performed. An unsupervised cluster analysis, incorporating 136 echocardiographic measures, was used to group patients with similar characteristics. Key measures differentiating the groups were then identified. RESULTS: Based on all measures, cluster analysis linked the 651 neonates into groups of 215 (Group 1), 338 (Group 2), and 98 (Group 3) patients. Aortic valve atresia and left ventricular (LV) end diastolic volume were identified as significant variables differentiating the groups. The median LV end diastolic area was 1.35, 0.69, and 2.47 cm2 in Groups 1, 2, and 3, respectively (p < 0.0001). Aortic atresia was present in 11% (24/215), 87% (294/338), and 8% (8/98), in Groups 1, 2, and 3, respectively (p < 0.0001). Balloon aortic valvotomy was the first intervention for 9% (19/215), 2% (6/338), and 61% (60/98), respectively (p < 0.0001). For those with an initial operation, single ventricle palliation was performed in 90% (176/215), 98% (326/338), and 58% (22/38) (p < 0.0001). Overall mortality in each group was 27% (59/215), 41% (138/338), and 12% (12/98) (p < 0.0001). CONCLUSIONS: Using a data-driven approach, we conceptualized three distinct patient groups, primarily based quantitatively on baseline LV size and qualitatively by the presence of aortic valve atresia. Management strategy and overall mortality differed significantly by group. These groups roughly correspond anatomically and are analogous to multi-level LV hypoplasia, hypoplastic left heart syndrome, and critical aortic stenosis, respectively. Our analysis suggests that quantitative and qualitative assessment of left heart structures, particularly LV size and type of aortic valve pathology, may yield conceptually more internally consistent groups than a simplistic scheme limited to valvar pathology alone.

The Utility of Flow Rate Compared with Left Ventricular Stroke Volume Index in the Hemodynamic Classification of Severe Aortic Stenosis with Preserved Ejection Fraction.

OBJECTIVES: To substitute the stroke volume index (SVi) with flow rate (FR) in the hemodynamic classification of severe aortic stenosis (AS) with preserved ejection fraction (EF), in order to evaluate its prognostic value. METHODS: A total of 529 patients (78.8 ± 9.8 years old, 44.1% males) with isolated severe AS (aortic valve area, AVA < 1 cm2), EF ≥50%, in sinus rhythm, who underwent transthoracic echocardiography, were stratified by FR (≥/< 200 mL/s) and mean pressure gradient (MG) (≥/< 40 mm Hg): FRnormal/MGhigh, FRlow/MGhigh, FRnormal/MGlow, and FRlow/MGlow. RESULTS: Aortic valve replacement was more frequently performed in the FRnormal/MGhigh than in the FRlow/MGlow group (69.3 vs. 47%, respectively, p < 0.0001), yielding a similar survival benefit across all four groups. Over a median follow-up of 51 ± 29 months, there were 249 deaths. In highly adjusted models, the FRlow/MGlow group had a higher all-cause mortality (HR = 1.7, 95% CI: 1.1-2.6, p = 0.02) than patients with FRnormal/MGhigh. FR had a stronger association with AVA than SVi (r = 0.51 vs. 0.41, respectively, p = 0.0002), and a similar predictive value for death (AUC = 0.57 and 0.58, respectively, p = 0.88). CONCLUSIONS: The FRlow/MGlow subset of AS is associated with the worst prognosis, and FR is not superior to SVi in the hemodynamic classification of severe AS.

New classification of geometric ventricular patterns in severe aortic stenosis: Could it be clinically useful?

BACKGROUND: In severe aortic stenosis, different left ventricle (LV) remodeling patterns as a response to pressure overload have distinct hemodynamic profiles, cardiac function, and outcomes. The most common classification considers LV relative wall thickness and LV mass index to create 4 different groups. A new classification including also end-diastolic volume index has been recently proposed. AIM: To describe the prevalence of the newly identified remodeling patterns in patients with severe aortic stenosis and to evaluate their clinical relevance according to symptoms. METHODS: We analyzed 286 consecutive patients with isolated severe aortic stenosis. Current guidelines were used for echocardiographic evaluation. Symptoms were defined as the presence of angina, syncope, or NYHA class III-IV. RESULTS: The mean age was 75 ± 9 years, 156 patients (54%) were men, while 158 (55%) were symptomatic. According to the new classification, the most frequent remodeling pattern was concentric hypertrophy (57.3%), followed by mixed (18.9%) and dilated hypertrophy (8.4%). There were no patients with eccentric remodeling; only 4 patients had a normalLV geometry. Symptomatic patients showed significantly more mixed hypertrophy (P < .05), while the difference regarding the prevalence of the other patterns was not statistically significant. When we analyzed the distribution of the classic 4 patterns stratified by the presence of symptoms, however, we did not find a significant difference (P = .157). CONCLUSIONS: The new classification had refined the description of different cardiac geometric phenotypes that develop as a response to pressure overload. It might be superior to the classic 4 patterns in terms of association with symptoms.

[Aortic stenosis is a common disease which requires individualized treatment]. / Aortastenos ­ en vanlig sjukdom som kräver individualiserad handläggning.

Aortic stenosis is the most common valvular heart disease and the prevalence increases with age. Common symptoms include dyspnea, angina, and syncope. Echocardiography is a cornerstone in diagnosis of aortic stenosis. Severe aortic stenosis is defined as peak aortic jet velocity ≥4 m/s, a mean transvalvular gradient ≥40 mmHg, and/or an aortic valve area <1.0 cm2. The two-year mortality in patients with symptomatic aortic stenosis is 50 percent without intervention. The only efficient treatment is intervention, either open heart valve replacement or percutaneous transcatheter implantation of an aortic valve prosthesis (TAVI), which both provide symptomatic relief and improved survival. Many patients with aortic stenosis are elderly with comorbidities, thus making treatment decision challenging and requiring individual judgement.

Take home messages with cases from focused update on echocardiographic assessment of aortic stenosis.

Echocardiography plays an important role in the assessment of valvular aortic stenosis. Updated recommendations focusing on a stepwise approach to evaluating aortic stenosis have recently been published by the European Association of Cardiovascular Imaging and the American Society of Echocardiography. This review uses illustrative cases to demonstrate technical aspects of aortic stenosis assessment and use of the new proposed classification scheme for aortic stenosis. Key points from the updated recommendations reviewed in this paper are: (1) technical considerations and sources of error in measurement of peak velocity, mean aortic valve gradient and aortic valve area by continuity equation. (2) Application of flow status using indexed left ventricular stroke volume to distinguish patients with low gradients and a low calculated aortic valve area. (3) Use of low-dose dobutamine stress echocardiography in patients with low ejection fraction. (4) Application of the new classification scheme and review of algorithm use for echocardiographic evaluation of severe aortic stenosis. Improved understanding of how to handle unmatched variables and adopting an integrated approach to determine severity is central to guiding the clinician's management of aortic stenosis.

Staging classification of aortic stenosis based on the extent of cardiac damage.

AIMS: In patients with aortic stenosis (AS), risk stratification for aortic valve replacement (AVR) relies mainly on valve-related factors, symptoms and co-morbidities. We sought to evaluate the prognostic impact of a newly-defined staging classification characterizing the extent of extravalvular (extra-aortic valve) cardiac damage among patients with severe AS undergoing AVR. METHODS AND RESULTS: Patients with severe AS from the PARTNER 2 trials were pooled and classified according to the presence or absence of cardiac damage as detected by echocardiography prior to AVR: no extravalvular cardiac damage (Stage 0), left ventricular damage (Stage 1), left atrial or mitral valve damage (Stage 2), pulmonary vasculature or tricuspid valve damage (Stage 3), or right ventricular damage (Stage 4). One-year outcomes were compared using Kaplan-Meier techniques and multivariable Cox proportional hazards models were used to identify 1-year predictors of mortality. In 1661 patients with sufficient echocardiographic data to allow staging, 47 (2.8%) patients were classified as Stage 0, 212 (12.8%) as Stage 1, 844 (50.8%) as Stage 2, 413 (24.9%) as Stage 3, and 145 (8.7%) as Stage 4. One-year mortality was 4.4% in Stage 0, 9.2% in Stage 1, 14.4% in Stage 2, 21.3% in Stage 3, and 24.5% in Stage 4 (Ptrend < 0.0001). The extent of cardiac damage was independently associated with increased mortality after AVR (HR 1.46 per each increment in stage, 95% confidence interval 1.27-1.67, P < 0.0001). CONCLUSION: This newly described staging classification objectively characterizes the extent of cardiac damage associated with AS and has important prognostic implications for clinical outcomes after AVR.

Survival and cause of death after transcatheter aortic valve replacement as compared to an age- and sex-matched background population.

AIMS: This study aimed to assess survival and causes of death in a real-world TAVR population as compared to an age- and sex-matched background population. METHODS AND RESULTS: Each aortic stenosis (AS) patient treated with TAVR in Eastern Denmark between 2007 and 2014 (n=617) was matched with 25 age- and sex-matched controls (n=15,425) randomly drawn from the general Danish population. In the total TAVR population, early mortality (≤90 days) was significantly higher (hazard ratio [HR] 3.90 [2.82-5.39]; p<0.001) as compared to its background population, driven mainly by cardiovascular (CV) mortality. Late mortality (>90 days) was not different between the TAVR and background population (HR 1.16 [0.96-1.40]; p=0.126), causes of death being mainly non-CV. In subgroup analysis, the HR for late mortality was 0.98, 1.11, and 1.90 for the low-, intermediate-, and high-risk TAVR groups, respectively, as compared to their matched controls and 1.04, 1.45, and 1.52 for the high gradient, paradoxical low-flow low-gradient (P-LFLG), and classical LFLG (C-LFLG) groups, respectively, as compared to their controls. CONCLUSIONS: In general, AS patients who survive the first three months after TAVR have a similar survival to their matched controls. Relative survival benefit is the highest in low-to-intermediate risk AS patients with a high transvalvular gradient.

Valvular Heart Disease in Adults: Etiologies, Classification, and Diagnosis.

The prevalence of valvular heart disease (VHD) in the United States was estimated to be approximately 2.5% in the 1990s. The prevalence currently is thought to be increasing because of more accurate diagnostic methods and aging of the population. Mitral regurgitation (MR) is the most common valve defect, followed by aortic stenosis (AS) and aortic regurgitation (AR). Degenerative disease is the most common etiology of MR, AS, and AR, though these forms of VHD also can be caused by congenital valve defects, systemic inflammatory diseases, endocarditis, and many other conditions. Mitral stenosis, most often caused by rheumatic fever, is uncommon in the United States. When VHD is suspected, transthoracic echocardiography should be obtained first. Other tests, including transesophageal echocardiography, computed tomography scan, magnetic resonance imaging study, and cardiac catheterization, are used in special situations to obtain more detailed diagnostic information. Guidelines for VHD management recommend interval monitoring with echocardiography. The exact interval recommended depends on the severity of the valve dysfunction and whether the patient is symptomatic. Monitoring of asymptomatic patients is important because early intervention, when valve function worsens or symptoms develop, is associated with better outcomes.

[Surgical treatment of aortic valve stenosis]. / Chirurgische Therapie der Aortenklappenstenose.

Surgical aortic valve replacement still represents the gold standard in patients with severe symptomatic aortic valve stenosis. In addition to conventional aortic valve replacement by mechanical or biological prostheses via a median sternotomy, novel approaches including minimally invasive strategies and new devices, such as so-called rapid deployment prostheses, are becoming increasingly more established. Autologous replacement strategies including the Ross and the Ozaki procedures have evolved into reliable options at selected centers of excellence. These novel treatment approaches in aortic valve surgery result in excellent short and long-term outcomes with a reduction of procedure-related complications. Taken together, these modern surgical replacement strategies enable a personalized surgical treatment in patients with aortic valve stenosis, which are tailored to the individual patient.