Long-term prognostic role of coronary flow velocity reserve in patients with aortic valve stenosis - insights from the SZEGED Study (original) (raw)
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Echocardiography, 2013
Patients with moderate and severe aortic stenosis (AS) and without obstructive epicardial coronary disease have been shown to have an impairment of coronary flow reserve (CFR). We investigated the prognostic significance of CFR in predicting death during mid-to-long-term follow-up in asymptomatic patients with moderate/severe AS, preserved ejection fraction (EF), and with nonobstructed coronary arteries. Method and Result: A total of 127 patients with moderate or severe AS (effective orifice area of 1.5 cm 2 or less), mean age 66 AE 11 were enrolled in this prospective study. The median follow-up was 32 AE 7 months. All patients had standard Doppler echo study, coronary angiography, and adenosinestress transthoracic Doppler echo for CFR measurement. Univariate analysis showed that diabetes mellitus, CFR, aortic valve area (AVA), maximal velocity (V max), mean pressure gradient (P mean), energy loss index (ELI), aortic valve resistance (AVR), NT-proBNP, E/E′, valvulo-arterial impedance (Z va), and stroke work loss (SWL) were associated (P < 0.05) with death. Multivariable logistic regression analysis revealed that only Z va and CFR were independent predictors of death, with the CFR being the single strongest predictor (Table 2). Using receiver operating characteristics (ROC) analysis, the CFR value of 1.85 had the highest accuracy in predicting the death during mid-to-long-term follow-up (area under the curve; AUC 0.890, P = 0.009, sensitivity 96.3%, specificity 75%; 95% CI 0.287-0.946; Fig. 1). The Z va value of 5.52 Hg/mL per m had a sensitivity 70.0% and specificity 72.0% (AUC 0.766, 95% CI 0.587-0.946; P = 0.005). Conclusion: This study demonstrates that CFR has a prognostic value in patients with asymptomatic moderate or severe AS with preserved EF and nonobstructed coronary arteries.
Structural Heart, 2017
Background: Whether risk-stratification in aortic valve stenosis (AS) should rely on a single hemodynamic parameter or a combination of hemodynamic parameters is still debated. We aimed to evaluate the prognostic value of mean pressure gradient (MPG), aortic valve area (AVA), and the dimensionless index (DI) in patients with AS and to test whether their combination provides additional prognostic information. Methods: We enrolled 319 asymptomatic patients with AS (90 mild, 173 moderate, and 56 severe AS). All patients were prospectively followed on a yearly basis and AS-related events (sudden death, heart failure, or new onset of AS-related symptoms) were collected. Results: After a mean follow-up of 3.1±1.7 years, an AS-related event occurred in 84 patients (26%). When considered in isolation, after adjustment for age, sex, history of coronary artery disease, valve anatomy, and left ventricular ejection fraction, each parameter (MPG, AVA, and DI) independently predicted the occurrence of AS-related events (all p<0.0001). When considered in combination, MPG and AVA (p=0.0009 and p<0.0001 respectively) or MPG and DI (p=0.0001 and p<0.0001 respectively) remained independent predictors of outcome. Results were sustained after exclusion of 31 patients (10%) with discordant grading. Conclusion: In a large prospective cohort of asymptomatic patients with a wide range of AS severity, AVA, MPG, and DI were all important prognostic factors. More importantly, irrespective of the presence of patients with discordant grading, MPG and either the AVA or the DI provided complementary prognostic information. Our results show that these hemodynamic parameters should be considered in combination in the clinical management of AS patients.
2013
Aortic valve stenosis (AS) in patients >75 years of age is a challenge for diagnosis and management of every day clinical routine. Therefore, this clinical follow-up study aims to investigate predictors of death in patients with advanced stages of AS. In a single-center study, all patients (n [ 157) with primary conservatively treated severe AS (mean age 78-6 years) were included. All patients had initially refused aortic valve replacement (AVR). During a median follow-up of 2.6 years (quartiles 1.7, 3.8), 62 patients with severe AS switched to AVR and 95 remained conservatively treated (no AVR). Routine clinical data were assessed together with conventional echocardiography including the measurement of longitudinal wall function and deformation (mitral ring displacement and longitudinal strain and strain rate imaging). The end points were all-cause and cardiac death. During follow-up, cardiac death occurred in 49% in no-AVR group. In a Cox regression analysis, New York Heart Association functional class, valvuloarterial impedance, stroke volume, longitudinal strain and strain rate, and mitral annular displacement identified an increased risk of all-cause death (hazard ratio [HR] for mitral annular displacement 15.9, 95% confidence interval [CI] 6.24 to 40.86, p <0.001, positive predictive value 91%). In contrast, ejection fraction or EuroSCORE was not predictive (ejection fraction: HR 1.3, 95% CI 0.82 to 2.33, p [ 0.25; EuroSCORE: HR 1.1, 95% CI 0.64 to 2.02, p [ 0.64). Furthermore, in multivariate regression analysis, only longitudinal mitral annular displacement and longitudinal strain rate was a significant predictor of all-cause and cardiac death risk. These data show that prognosis in elderly patients with AS is determined by symptoms, hemodynamics, and particularly by cardiac long-axis function. Thus, for risk stratification, a comprehensive assessment of cardiac function including the measurement of longitudinal mitral annular displacement should be considered.
Journal of Cardiology, 2016
Background: Current prognostic implication of symptomatic patients with aortic stenosis (AS) remains undetermined. This study investigated the current prognostic implications of AS-related symptoms and the effect of aortic valve replacement (AVR) on outcome. Methods: We enrolled 586 consecutive patients with severe AS (aortic valve area <1.0 cm 2) with preserved left ventricular ejection fraction (!50%). All patients were stratified into the following four groups based on the predominant symptoms: Group 1, asymptomatic (n = 316); Group 2, chest pain (n = 41); Group 3, heart failure (n = 192); or Group 4, syncope (n = 37). Results: AS-related symptoms were diagnosed in 270 patients (46.1%), among whom 182 patients (32.2%) received AVR. Thirty-nine patients (6.7%) had cardiac death during the mean follow-up of 16 AE 14 months. AVR was associated with significant reduction in cardiac death in Groups 3 (p < 0.001) and 4 (p = 0.004) whereas no significant prognostic advantage of AVR was observed in Groups 1 or 2. Cox proportional-hazard multivariate analysis revealed that age, heart failure, and mean pressure gradient (PG) were associated with increased risk of cardiac death in all patients regardless of AVR [hazard ratio (HR): 1.079, 2.090, and 1.008 respectively, all p < 0.05]. In the patients without AVR, age, heart failure, syncope, and mean PG were independently associated with cardiac death (HR: 1.130, 3.639, 4.638, and 1.008, all p < 0.05). Conclusion: This retrospective study demonstrated the current associations between the types of AS symptoms and prognosis in Japanese patients with severe AS.
Prognostic Value of Energy Loss Index in Asymptomatic Aortic Stenosis
2013
C urrent guidelines recommend a variety of Doppler echocardiographic measures for assessing the severity of aortic stenosis (AS), including peak aortic jet velocity, mean aortic gradient, aortic valve area (AVA), and AVA indexed for body surface area (AVAI). 1-5 These measures may categorize the severity of AS differently, and inconsistently graded severe AS has been reported in up to 30% of patients. 6 In particular, AS severity is frequently overestimated by AVAI in patients with milder degree of AS if pressure recovery in the aortic root is not taken into account. 7 Recently, it was demonstrated that patients with inconsistently graded severe AS had a prognosis comparable to that seen in patients with moderate AS. 8 Whether assessment of pressure recovery adjusted AVAI (energy loss index [ELI]) in this setting could add accuracy to risk assessment is unknown. Editorial see p 1101 Clinical Perspective on p 1156 In AS, therapeutic decisions are based on symptomatic status, hemodynamic severity, and left ventricular function. 1,4 Accurate echocardiographic assessment of AS severity is of major clinical importance. It has been suggested that ELI may more accurately reflect the severity of AS. 9-11 However, the prognostic value of ELI has not been assessed in a large, prospective study. Thus, the aim of the present analysis was to determine whether ELI was superior to conventional, commonly used measures of AS severity in predicting aortic valve events (AVEs) and total mortality in initially asymptomatic AS patients. Methods Study Population The present analysis was prospectively planned within the Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study, which enrolled 1873 Background-Aortic valve area index adjusted for pressure recovery (energy loss index [ELI]) has been suggested as a more accurate measure of aortic stenosis (AS) severity, but its prognostic value has not been determined in a prospective study. Methods and Results-The relation between baseline ELI and rate of aortic valve events and combined total mortality and hospitalization for heart failure resulting from the progression of AS was assessed by multivariate Cox regression and reclassification analysis in 1563 patients with initial asymptomatic AS in the Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study. During 4.3 years follow-up, a total of 498 aortic valve events and 181 combined total mortalities and hospitalizations for heart failure caused by the progression of AS occurred. In Cox regression analyses, 1-cm 2 /m 2 lower baseline ELI predicted a 2-fold higher risk both for aortic valve events and for combined total mortality and hospitalization for heart failure independently of baseline peak aortic jet velocity or mean aortic gradient and independently of aortic root size (all P<0.05). In reclassification analysis, ELI improved the prediction of aortic valve events by 13% (95% confidence interval, 5-19), whereas the prediction of combined total mortality and hospitalization for heart failure resulting from the progression of AS did not improve significantly. Conclusions-In asymptomatic AS patients without known atherosclerotic disease or diabetes mellitus, ELI provides independent and additional prognostic information to that derived from conventional measures of AS severity, suggesting that ELI should be measured in such patients.
Echocardiography, 2010
Objective: Coronary flow velocity reserve (CFR) by pulsed Doppler echocardiography is a useful hemodynamic index to evaluate the coronary microcirculatory dysfunction in the left anterior descending coronary artery (LAD). The present study was designed to evaluate the long-term predictive value of CFR for mortality in patients with right (RC) and/or left circumflex coronary artery (CX) stenosis without epicardial LAD disease. Methods: A total of 49 patients with significant RC and/or CX stenosis were enrolled in this prospective follow-up study. All patients had undergone coronary angiography demonstrating significant RC and/or CX stenosis without LAD disease and dipyridamole stress transoesophageal echocardiography as CFR measurement. Results: The success rate of follow-up was 43 out of 49 (88%). During a mean follow-up of 97 ± 29 months, 14 patients suffered cardiovascular deaths (12 sudden cardiac deaths and 2 strokes), and 1 patient died of pulmonal tumor. Patients who died during the follow-up had significantly lower CFR values (1.85 ± 0.43 vs. 2.31 ± 0.57, P < 0.05). Using ROC analysis, CFR <2.09 had the highest accuracy in predicting cardiovascular survival (sensitivity 80%, specificity 57%, area under the curve 73%, P = 0.003). The logistic regression model identified only CFR as an independent predictor of survival (hazard ratio [HR] 6.26, 95% CI of HR 1.23-19.61, P = 0.024). Conclusions: Long-term prognostic significance of CFR for the prediction of mortality has been demonstrated during a 9-year follow-up in patients with significant coronary artery disease not involving the LAD. (Echocardiography 2010;27:306-310)
Hemodynamic Progression and Outcome of Asymptomatic Aortic Stenosis in Primary Care
The American Journal of Cardiology, 2012
The prognostic relevance of a rapid rate of hemodynamic progression of aortic stenosis (AS) has been predominantly investigated in tertiary centers. We reviewed the clinical and echocardiographic data from 153 asymptomatic patients with AS (age 77 ؎ 9 years; 65% men), with normal left ventricular function and paired echocardiograms >4 months apart (mean 2.9 ؎ 2.1 years), evaluated in a nonreferral echocardiographic laboratory. The severity of AS was graded by the peak aortic velocity (Vmax) and progression was classified as slow or fast according to a cutoff value of 0.3 m/s increase annually. The end points were all-cause mortality and a composite of all-cause mortality and aortic valve replacement (AVR). At baseline, 135 patients (88%) had mild-to-moderate and 18 (12%) severe AS. Of the 153 patients, 49 (32%) showed fast progression (0.61 ؎ 0.32 m/s/yr) and 104 (68%) had slow progression (0.10 ؎ 0.16 m/s/yr). Among the 144 patients (94%) with clinical follow-up data, 40 died and 48 underwent AVR. The mortality rate was greater than that of the general population (p <0.001). On multivariate analysis, the independent predictors of mortality were the yearly change in Vmax (hazard ratio [HR] 13.352 per m/s increase, 95% confidence interval [CI] 5.136 to 34.713, p <0.001) and age (HR 1.122 per year, 95% CI 1.0728 to 1.735, p <0.001). The predictors of the composite end point of death and AVR
International Journal of Cardiovascular Imaging, 2003
Background: The present study was conducted to examine whether it is possible to differentiate patients with aortic stenosis (AOS) with or without significant stenosis of the left anterior descending coronary artery (LAD) on the basis of the age, gender, hypertension, diabetes mellitus, hypercholesterolemia, the coronary flow velocity reserve (CFVR) and the grade of aortic atherosclerosis (AA) evaluated by TEE in the course of the same semi-invasive examination. Patients and methods: Thirty-nine consecutive AOS patients who had undergone coronary angiography were examined by dipyridamole stress TEE to assess the CFVR. From this patient population, 21 AOS patients with anatomically normal coronary arteries (group 1), and 18 AOS patients with >75% stenosis of the LAD (group 2) were selected for the present study. The CFVR was calculated as the ratio of the average peak diastolic flow velocity (APV) during hyperemia to the resting APV. The grade of AA in the descending aorta was determined by means of the same TEE examination. Results: The demographic, clinical and transthoracic echocardiographic data, the coronary flow velocities and the CFVRs were similar in the two patient groups. Only the grade of AA (ROC area, 73%, p <0.02) appears useful for the distinction of AOS patients with or without significant LAD stenosis. Conclusions: These results demonstrate that only the grade of AA furnishes additional help in the prediction of AOS patients with severe LAD disease. CFVR has no any diagnostic power in the differentiation of AOS patients with or without significant LAD stenosis.
International Journal of Cardiology, 2008
Background: The degree of aortic atherosclerosis (AA) and coronary flow reserve (CFR) can be evaluated simultaneously during the same transoesophageal echocardiographic (TEE) examination. The aim of the present study was to assess the relative prognostic value of simultaneously evaluated CFR and AA by TEE in patients with suspected or known coronary artery disease (CAD). Methods: The present study comprised 397 inhospital patients with chest pain. All patients underwent a transthoracic echocardiographic study to evaluate left ventricular function and a vasodilator TEE study to evaluate simultaneously CFR and the degree of AA. Results: Coronary angiography was performed in 292 patients (74%). Significant CAD was less frequent in patients with normal CFR and lowgrade AA. During a mean follow-up of 41 ± 12 months, 23 patients suffered cardiovascular death (14 sudden cardiac death, 7 heart failure, 2 cardiovascular thrombosis). Univariate analysis yielded age, diabetes, AA grade and CFR as predictors of survival. Multivariate regression analysis showed that only CFR (hazard ratio (HR) 2.9, P b 0.02) and diabetes (HR 3.8, P b 0.01) were independent predictors of survival. Conclusions: It can be said that both CFR and AA grade are associated with poor survival but only CFR is an independent predictor.