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Cardiac Damage in Patients With Symptomatic Aortic Stenosis
Study Questions:
Does an echo/Doppler staging system assessing cardiac abnormalities distinct from the aortic valve help predict clinical outcomes among symptomatic patients with severe aortic stenosis (AS)?
Methods:
Ongoing registries from two academic institutions were used for the retrospective analysis of prospectively collected data from 1,189 symptomatic patients with severe AS (mean age 73 ± 11 years, 53% male). Patients were classified according to a recently defined staging classification that addresses cardiac abnormalities distinct from the aortic valve among patients with AS:
- Stage 0: No cardiac damage associated with AS
- Stage 1: Left ventricular (LV) damage defined by LV hypertrophy (LV mass index >115 g/m2 in men or >95 g/m2 in women) and/or mitral E/e’ >14 and/or LV ejection fraction (LVEF) <60%
- Stage 2: Left atrial (LA) or mitral valve damage defined by LA volume index >34 ml/m2 and/or atrial fibrillation and/or ≥ moderate mitral regurgitation
- Stage 3: Pulmonary vasculature or tricuspid valve damage defined by pulmonary artery systolic pressure >60 mm Hg and/or ≥ moderate tricuspid regurgitation
- Stage 4: Right ventricular (RV) damage or subclinical heart failure defined by a multiparameter approach including semiquantitative assessment by visual examination and quantitative assessment using tricuspid annulus systolic velocity S’ <9.5 cm/s and/or tricuspid annular plane systolic excursion <17 mm
Patients were followed for all-cause mortality and the combined endpoint of all-cause mortality, stroke, and cardiac-related hospitalization.
Results:
A total of 917 patients (77%) underwent aortic valve replacement (AVR; 47% transcatheter and 53% surgical) with a median time of 67 (interquartile range [IQR], 5-197) days. During follow-up of 42 (IQR, 20-77) months, 472 patients (40%) died; over a median time of 35 (IQR, 14-67) months, 617 patients (52%) reached the combined endpoint (all-cause mortality, stroke, and cardiac-related hospitalization). On the basis of the proposed classification, 8% of patients were classified as Stage 0, 24% as Stage 1, 49% as Stage 2, 7% as Stage 3, and 12% as Stage 4. On multivariable analysis, age, previous myocardial infarction, renal function, surgical or transcatheter AVR, and stage of cardiac damage were independently associated with all-cause mortality. For each increase in stage, there was a 28% higher risk for all-cause mortality (95% confidence interval [CI], 1.158-1.422; p < 0.001). However, only Stage 3 (hazard ratio [HR], 1.975; 95% CI, 1.125-3.469; p = 0.018) and Stage 4 (HR, 2.472; 95% CI, 1.471-4.155; p = 0.001) were independently associated with all-cause mortality. For the combined endpoint, age, previous myocardial infarction, renal function, surgical or transcatheter AVR, and stage of cardiac damage were independent predictors on multivariable analysis; with a 19% increase in risk for the combined outcome for each increasing stage (95% CI, 1.091-1.299; p < 0.001). Among patients who underwent AVR, stage of cardiac damage was significantly associated with both total and postoperative all-cause mortality and with the combined outcome; but only Stage 4 was independently associated with outcomes when considering separate stages of cardiac damage.
Conclusions:
In this two-center cohort of symptomatic patients with severe AS, the stage of cardiac injury classified by a new staging system was independently associated with all-cause mortality and a combined clinical endpoint of all-cause mortality, stroke, and cardiac-related hospitalization; however, this was driven predominantly by tricuspid valve or pulmonary artery vascular damage (Stage 3) and RV dysfunction (Stage 4).
Perspective:
These data suggest that a staging system that assesses cardiac abnormalities separate from the aortic valve has prognostic power among symptomatic patients with severe AS, but that the relationship predominantly was influenced by patients with Stage 3 (pulmonary hypertension) or 4 (RV dysfunction) disease. The finding that pulmonary hypertension and/or RV dysfunction carry an adverse prognosis among patients with another cardiac disease is not novel. It remains to be seen whether the described staging system has clinical utility in the management of patients with severe AS. (See the related article: Tastet L, et al., J Am Coll Cardiol 2019;74:550-63).
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Valvular Heart Disease, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Pulmonary Hypertension, Interventions and Imaging, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Echocardiography/Ultrasound, Hypertension, Mitral Regurgitation
Keywords: Aortic Valve Stenosis, Atrial Fibrillation, Blood Pressure, Cardiac Surgical Procedures, Echocardiography, Doppler, Geriatrics, Heart Failure, Heart Valve Diseases, Heart Valve Prosthesis, Hypertension, Pulmonary, Hypertrophy, Mitral Valve Insufficiency, Myocardial Infarction, Stroke, Stroke Volume, Systole, Transcatheter Aortic Valve Replacement, Tricuspid Valve Insufficiency
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