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

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          Abstract

          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 cm<sup>2</sup>), EF ≥50%, in sinus rhythm, who underwent transthoracic echocardiography, were stratified by FR (≥/< 200 mL/s) and mean pressure gradient (MG) (≥/< 40 mm Hg): FR<sub>normal</sub>/MG<sub>high</sub>, FR<sub>low</sub>/MG<sub>high</sub>, FR<sub>normal</sub>/MG<sub>low</sub>, and FR<sub>low</sub>/MG<sub>low</sub>. Results: Aortic valve replacement was more frequently performed in the FR<sub>normal</sub>/MG<sub>high</sub> than in the FR<sub>low</sub>/MG<sub>low</sub> 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 FR<sub>low</sub>/MG<sub>low</sub> group had a higher all-cause mortality (HR = 1.7, 95% CI: 1.1–2.6, p = 0.02) than patients with FR<sub>normal</sub>/MG<sub>high</sub>. 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 FR<sub>low</sub>/MG<sub>low</sub> subset of AS is associated with the worst prognosis, and FR is not superior to SVi in the hemodynamic classification of severe AS.

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          Clinical outcome in asymptomatic severe aortic stenosis: insights from the new proposed aortic stenosis grading classification.

          Patrizio Lancellotti, Julien Magne, Erwan Donal … (2012)
          This study examined the clinical course of patients with asymptomatic severe aortic stenosis (AS) according to the new proposed aortic valve stenosis grading classification. The management of patients with asymptomatic severe AS remains controversial. Moreover, under the same denomination of severe AS, several entities might be identified according to transvalvular flow rates and pressure gradients, resulting in 4 flow-gradient patterns. Transthoracic echocardiography and measurement of B-type natriuretic peptide level from venous blood sample were performed in 150 consecutive patients with asymptomatic severe AS and normal exercise test. Patients were classified in 4 groups, depending on left ventricular flow state (normal flow [NF] vs. low flow [LF]: 35 ml/m(2)) and pressure gradient levels (low gradient [LG] vs. high gradient [HG]: 40 mm Hg). Patients with NF/LG had significantly lower B-type natriuretic peptide than those with LF/HG and LF/LG. The mean follow-up was 27 ± 12 months. At 2 years, cardiac event-free survival was 83 ± 6%, 44 ± 6%, 30 ± 12%, and 27 ± 13% in NF/LG, NF/HG, LF/HG, and LF/LG groups, respectively (p < 0.0001). On multivariable analysis, LF/LG (hazard ratio [HR]: 5.26, 95% confidence interval [CI]: 2.04 to 14.3, p = 0.045) and LF/HG (HR: 2.38, 95% CI: 1.02 to 5.55, p = 0.001) were identified as strong independent determinants of poor prognosis as compared with NF/HG. By limiting the multivariable analysis to patients with LF, LF/LG was an independent predictor of markedly reduced cardiac event-free survival when compared with LF/HG (HR: 5.4, 95% CI: 1.03 to 28.6, p = 0.046). The use of the new proposed AS grading classification integrating valve area and flow-gradient patterns allows a better characterization of the clinical outcome of patients with asymptomatic severe AS. Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
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            Low-gradient aortic valve stenosis myocardial fibrosis and its influence on function and outcome.

            Markus Niemann, J Strotmann, Sebastian Herrmann … (2011)
            This prospective cohort study in patients with aortic stenosis (AS) aimed to identify surrogates of myocardial fibrosis that are easy to derive in clinical practice, allow the differentiation of low-gradient severe AS from moderate AS, and have an impact on clinical outcome. In patients with symptomatic aortic AS, a characteristic subgroup (i.e., up to one-third) exhibits severe AS with a concomitant low mean valve gradient either with preserved or reduced ejection fraction (EF). It is hypothesized that these patients tend to have an advanced stage of myocardial fibrosis and poor clinical outcome. Eighty-six patients with moderate or severe AS were examined by echocardiography including conventional aortic valve assessment, mitral ring displacement, and strain-rate imaging. Replacement fibrosis was quantified by late-enhancement magnetic resonance imaging. Biopsy samples were taken from patients with severe AS (n = 69) at aortic valve replacement. All patients were followed for 9 months. Patients were divided into 4 groups according to aortic valve area (<1.0 cm(2)), mean valve gradient ≥40 mm Hg, and EF (<50%): group 1, moderate AS (n = 17); group 2, severe AS/high gradient (n = 49); group 3, severe AS/low gradient/preserved EF (n = 11); and group 4, severe AS/low gradient/decreased EF (n = 9). At baseline, a significant decrease in mitral ring displacement and systolic strain rate was detected in patients with low-gradient AS. In low-gradient groups, a higher degree of interstitial fibrosis in biopsy samples and more late-enhancement magnetic resonance imaging segments were observed. A close inverse correlation was found between interstitial fibrosis and mitral ring displacement (r = -0.79, p < 0.0001). Clinical outcome was best for patients in group 1, whereas mortality risk increased substantially in groups 2 through 4. In severe AS, a low gradient is associated with a higher degree of fibrosis, decreased longitudinal function, and poorer clinical outcome despite preserved EF. Mitral ring displacement differentiates between moderate AS and low-gradient/severe AS with preserved EF. Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
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              Outcome of patients with low-gradient "severe" aortic stenosis and preserved ejection fraction.

              Antero Y. Kesäniemi, Kurt Boman, Christa Gohlke-Bärwolf … (2011)
              Retrospective studies have suggested that patients with a low transvalvular gradient in the presence of an aortic valve area < 1.0 cm² and normal ejection fraction may represent a subgroup with an advanced stage of aortic valve disease, reduced stroke volume, and poor prognosis requiring early surgery. We therefore evaluated the outcome of patients with low-gradient "severe" stenosis (defined as aortic valve area < 1.0 cm² and mean gradient ≤ 40 mm Hg) in the prospective Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study. Outcome in patients with low-gradient "severe" aortic stenosis was compared with outcome in patients with moderate stenosis (aortic valve area 1.0 to 1.5 cm²; mean gradient 25 to 40 mm Hg). The primary end point of aortic valve events included death from cardiovascular causes, aortic valve replacement, and heart failure due to aortic stenosis. Secondary end points were major cardiovascular events and cardiovascular death. In 1525 asymptomatic patients (mean age, 67 ± 10 years; ejection fraction, ≥ 55%), baseline echocardiography revealed low-gradient severe stenosis in 435 patients (29%) and moderate stenosis in 184 (12%). Left ventricular mass was lower in patients with low-gradient severe stenosis than in those with moderate stenosis (182 ± 64 versus 212 ± 68 g; P < 0.01). During 46 months of follow-up, aortic valve events occurred in 48.5% versus 44.6%, respectively (P = 0.37; major cardiovascular events, 50.9% versus 48.5%, P = 0.58; cardiovascular death, 7.8% versus 4.9%, P = 0.19). Low-gradient severe stenosis patients with reduced stroke volume index (≤ 35 mL/m²; n = 223) had aortic valve events comparable to those in patients with normal stroke volume index (46.2% versus 50.9%; P = 0.53). Patients with low-gradient "severe" aortic stenosis and normal ejection fraction have an outcome similar to that in patients with moderate stenosis.
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                Author and article information

                Journal
                Journal ID (publisher-id): CRD
                Journal ID (nlm-ta): Cardiology
                Journal ID (doi): 10.1159/issn.0008-6312
                Title: Cardiology
                Publisher: S. Karger AG
                ISSN (Print): 0008-6312
                ISSN (Electronic): 1421-9751
                Publication date Subscription-year: 2018
                Publication date (Print): November 2018
                Publication date (Electronic): 10 October 2018
                Volume: 141
                Issue: 1
                Pages: 37-45
                Affiliations
                St. Francis Hospital/SUNY at Stony Brook, Roslyn, New York, USA
                Author notes
                *Eddy Barasch, MD, Department of Research and Education, St. Francis Hospital, 100 Port Washington Blvd., Roslyn, NY 11576 (USA), E-Mail eddy.barasch@chsli.org
                Article
                Publisher ID: 493165 Other ID: Cardiology 2018;141:37–45
                DOI: 10.1159/000493165
                PubMed ID: 30304720
                SO-VID: d1dc4e01-278a-4017-95d4-a37dda890de4
                Copyright © © 2018 S. Karger AG, Basel
                License:

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                History
                Date received : 09 July 2018
                Date accepted : 20 August 2018
                Page count
                Figures: 3, Tables: 5, Pages: 9
                Categories
                Subject: Original Research

                ScienceOpen disciplines: General medicine,Neurology,Cardiovascular Medicine,Internal medicine,Nephrology
                Keywords: Aortic stenosis,Stroke volume index,Flow rate
                Data availability:
                ScienceOpen disciplines: General medicine, Neurology, Cardiovascular Medicine, Internal medicine, Nephrology
                Keywords: Aortic stenosis, Stroke volume index, Flow rate

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