[en] OBJECTIVE: We sought to evaluate prognostic markers of clinical outcome in asymptomatic patients with moderate to severe aortic stenosis (AS). DESIGN: Prospective follow-up of asymptomatic patients with moderate to severe AS. The patients underwent clinical and Doppler echocardiographic evaluation. SETTING: Department of Cardiology. PATIENTS: 163 patients with moderate to severe AS (aortic valve area < or =0.6 cm(2)/m(2)). MAIN OUTCOME MEASURES: Risk stratification. Predefined endpoints for assessing the outcome were the occurrence during follow-up of symptoms, aortic valve replacement or death. RESULTS: During follow-up (mean, 20 (19) months), 11 patients developed symptoms but were not operated on, 57 required aortic valve replacement and six patients died. In multivariable Cox regression analysis, four parameters that were associated with the outcome were identified: peak aortic jet velocity, left ventricular systolic (LV) longitudinal deformation, valvulo-arterial impedance and indexed left atrial area. Using receiver-operator characteristic curve analysis, a peak aortic jet velocity > or =4.4 m/s, a LV longitudinal myocardial deformation < or =15.9%, a valvular-arterial impedance > or =4.9 mm Hg/ml per m(2) and an indexed left atrial area > or =12.2 cm(2)/m(2) were identified as the best cut-off values to be associated with events. CONCLUSIONS: In asymptomatic patients with moderate to severe AS, measurements that integrate the ventricular, vascular and valvular components of the disease improve risk stratification.
Disciplines :
General & internal medicine Cardiovascular & respiratory systems
Author, co-author :
Lancellotti, Patrizio ; Université de Liège - ULiège > Département des sciences cliniques > Imagerie cardiaque fonctionnelle par échographie
Donal, Erwan; CHU de Ponchaillou, Rennes, France
Magne, Julien ; Université de Liège - ULiège > Département des sciences cliniques > Cardiologie - Pathologie spéciale et réhabilitation
Moonen, Marie ; Université de Liège - ULiège > Département des sciences cliniques > Imagerie cardiaque fonctionnelle par échoraphie
O'Connor, Kim; Université de Liège - ULiège > Département des sciences cliniques > Imagerie cardiaque fonctionnelle par échographie
Daubert, Jean-Claude; CHU de Ponchaillou, Rennes, France
Pierard, Luc ; Université de Liège - ULiège > Département des sciences cliniques > Imagerie cardiaque fonctionnelle par échographie
Language :
English
Title :
Risk stratification in asymptomatic moderate to severe aortic stenosis: the importance of the valvular, arterial and ventricular interplay.
Otto CM. Valvular aortic stenosis: disease severity and timing of intervention. J Am Coll Cardiol 2006;47:2141-51.
Rosenhek R, Binder T, Porenta G, et al. Predictors of outcome in severe, asymptomatic aortic stenosis. N Engl J Med 2000;343:611-17.
Rahimtoola SH. Valvular heart disease: a perspective on the asymptomatic patient with severe valvular aortic stenosis. Eur Heart J 2008;29:1783-90.
Bonow RO, Carabello BA, Kanu C, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (writing committee to revise the 1998 guidelines for the management of patients with valvular heart disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation 2006;114:e84-231.
Vahanian A, Baumgartner H, Bax J, et al. Guidelines on the management of valvular heart disease: the task force on the management of valvular heart disease of the European Society of Cardiology. Eur Heart J 2007;28:230-68.
Skjaerpe T, Hegrenaes L, Hatle L. Noninvasive estimation of valve area in patients with aortic stenosis by Doppler ultrasound and two-dimensional echocardiography. Circulation 1985;72:810-18.
Schiller N, Shah P, Crawford M, et al. Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. American Society of Echocardiography committee on standards, subcommittee on quantitation of two-dimensional echocardiograms. J Am Soc Echocardiograph 1989;2:358-67.
Pierard LA, Lancellotti P. The role of ischemic mitral regurgitation in the pathogenesis of acute pulmonary edema. N Engl J Med 2004;351:1627-34.
Lancellotti P, Cosyns B, Zacharakis D, et al. Importance of left ventricular longitudinal function and functional reserve in patients with degenerative mitral regurgitation: assessment by two-dimensional speckle tracking. J Am Soc Echocardiogr 2008;21:1331-6.
Briand M, Dumesnil JG, Kadem L, et al. Reduced systemic arterial compliance impacts significantly on left ventricular afterload and function in aortic stenosis: implications for diagnosis and treatment. J Am Coll Cardiol 2005;46:291-8.
Bergler-Klein J, Klaar U, Heger M, et al. Natriuretic peptides predict symptom-free survival and postoperative outcome in severe aortic stenosis. Circulation 2004;109:2302-8.
Pellikka PA, Sarano ME, Nishimura RA, et al. Outcome of 622 adults with asymptomatic, hemodynamically significant aortic stenosis during prolonged follow-up. Circulation 2005;111:3290-5.
Otto CM, Burwash IG, Legget ME, et al. Prospective study of asymptomatic valvular aortic stenosis. Clinical, echocardiographic, and exercise predictors of outcome. Circulation 1997;95:2262-70.
Rosenhek R, Klaar U, Schemper M, et al. Mild and moderate aortic stenosis: natural history and risk stratification by echocardiography. Eur Heart J 2004;25:199-205.
Das P, Rimington H, Chambers J. Exercise testing to stratify risk in aortic stenosis. Eur Heart J 2005;26:1309-13.
Lancellotti P, Lebois F, Simon M, et al. Prognostic importance of quantitative exercise doppler echocardiography in asymptomatic valvular aortic stenosis. Circulation 2005;112:I377-82.
Rosenhek R, Zilberszac R, Schemper M, et al. Natural history of very severe aortic stenosis. Circulation 2010;121:151-6.
Rajamannan NM, Bonow RO, Rahimtoola SH. Calcific aortic stenosis: an update. Nat Clin Pract Cardiovasc Med 2007;4:254-62.
Vinereanu D, Nicolaides E, Boden L, et al. Conduit arterial stiffness is associated with impaired left ventricular subendocardial function. Heart 2003;89:449-50.
Hachicha Z, Dumesnil JG, Pibarot P. Usefulness of the valvuloarterial impedance to predict adverse outcome in asymptomatic aortic stenosis. J Am Coll Cardiol 2009;54:1003-11.
Alsaileek AA, Osranek M, Fatema K, et al. Predictive value of normal left atrial volume in stress echocardiography. J Am Coll Cardiol 2006;47:1024-8.
Pritchett AM, Jacobsen SJ, Mahoney DW, et al. Left atrial volume as an index of left atrial size: a population-based study. J Am Coll Cardiol 2003;41:1036-43.
Rossi A, Tomaino M, Golia G, et al. Usefulness of left atrial size in predicting postoperative symptomatic improvement in patients with aortic stenosis. Am J Cardiol 2000;86:567-70.
Hein S, Arnon E, Kostin S, et al. Progression from compensated hypertrophy to failure in the pressure-overloaded human heart: structural deterioration and compensatory mechanisms. Circulation 2003;107:984-91.
Lafitte S, Perlant M, Reant P, et al. Impact of impaired myocardial deformations on exercise tolerance and prognosis in patients with asymptomatic aortic stenosis. Eur J Echocardiogr 2008;10:414-19.
Cramariuc D, Cioffi G, Rieck AE, et al. Low-flow aortic stenosis in asymptomatic patients: valvular-arterial impedance and systolic function from the SEAS substudy. JACC Cardiovasc Imaging 2009;2:390-9.
Tongue AG, Dumesnil JG, Laforest I, et al. Left ventricular longitudinal shortening in patients with aortic stenosis: relationship with symptomatic status. J Heart Valve Dis 2003;12:142-9.
Van Pelt NC, Stewart RA, Legget ME, et al. Longitudinal left ventricular contractile dysfunction after exercise in aortic stenosis. Heart 2007;93:732-8.
