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Aortic Stenosis Progression, Cardiac Damage, and Survival
Quick Takes
- Patients with BAV-AS and TAV-AS had similar AS progression rates, with evidence of accelerated progression (nonlinearity) in those attaining severe and very severe AS.
- Of note, whereas determinants of rapid progression in TAV-AS were nonmodifiable, modifiable cardiac risk factors were strong determinants of rapid progression in BAV-AS, particularly for patients with BAV <60 years of age.
- The totality of AS burden (i.e., cardiac disease) is a crucial concept for TAV-AS, whereas attention to modifiable risk factors may be preventive for patients with BAV-AS.
Study Questions:
What are the aortic stenosis (AS) progression rates, AS-related cardiac damage (AS-CD) indicator incidence and determinants, and survival between patients with tricuspid aortic valve (TAV)-AS and those with bicuspid aortic valve (BAV)-AS?
Methods:
The investigators retrospectively studied consecutive patients with baseline peak aortic valve velocity (peakV) ≥2.5 m/s and left ventricular ejection fraction ≥50%. Follow-up echocardiograms (n = 4,818) provided multiparametric AS progression rates and AS-CD. Mixed linear models with a random per patient intercept were used to determine annualized progression rates of peakV, mean pressure gradient (MPG), and aortic valve area in a different AS severity category by designating time 0 as the last available transthoracic echocardiogram and earlier measurements as negative [–] time duration.
Results:
The study included 330 BAV (54 ± 14 years) and 581 patients with TAV (72 ± 11 years). At last echocardiogram (median, 5.9 years; interquartile range, 3.9-8.5 years), BAV-AS exhibited similar peakV and MPG as TAV-AS, but larger calculated aortic valve area due to larger aortic annulus (p < 0.0001). Multiparametric progression rates were similar between BAV-AS and TAV-AS (all p ≥ 0.08) and did not predict age-/sex-adjusted survival (p ≥ 0.45). Independent determinants of rapid progression were male sex and baseline AS severity for TAV (all p ≤ 0.024), and age, baseline AS severity, and cardiac risk factors (age interaction: p = 0.02) for BAV (all p ≤ 0.005). At 12 years, patients with TAV-AS had a higher incidence of AS-CD than BAV-AS patients (p < 0.0001), resulting in significantly worse survival compared to BAV-AS (p < 0.0001). AS-CD were independently determined by multiple factors (MPG, age, sex, comorbidities, cardiac function; all p ≤ 0.039), and BAV was independently protective of most AS-CD (all p ≤ 0.05).
Conclusions:
The authors concluded that TAV-AS and BAV-AS progression rates were overall similar.
Perspective:
This cohort study reports that patients with BAV-AS and with TAV-AS had similar AS progression rates, with evidence of accelerated progression (nonlinearity) in those attaining severe and very severe AS. Of note, whereas determinants of rapid progression in TAV-AS were nonmodifiable, modifiable cardiac risk factors were strong determinants of rapid progression in BAV-AS, particularly for patients with BAV <60 years of age. The totality of AS burden (i.e., cardiac disease) is a crucial concept for TAV-AS, whereas attention to modifiable risk factors may be preventive for patients with BAV-AS. There is an apparent need for trials of medical therapies to delay or prevent AS progression, especially in patients with BAV.
Clinical Topics: Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Valvular Heart Disease, Acute Heart Failure, Echocardiography/Ultrasound
Keywords: Aortic Valve Stenosis, Diagnostic Imaging, Disease Progression, Echocardiography, Heart Failure, Heart Valve Diseases, Risk Factors, Secondary Prevention, Stroke Volume, Tricuspid Valve Stenosis, Ventricular Function, Left
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