Life expectancy after surgical aortic valve replacement for low-gradient aortic stenosis with preserved ejection fraction.

INTRODUCTION AND OBJECTIVES: Surgical aortic valve replacement (SAVR) can modify the natural history of severe aortic stenosis (SAS). However, compared with the general population, these patients have a loss of life expectancy. The life expectancy of patients who undergo SAVR due to low-gradient SAS with preserved left ventricular ejection fraction (LVEF) is unknown. METHODS: We included all patients between 50 and 65 years who underwent isolated SAVR in 27 Spanish centers during an 18-year period. We analyzed observed and expected survival at 18 years in patients with low-gradient SAS with preserved LVEF and all other types of SAS. We used propensity score matching to compare the life expectancy of patients with low-gradient SAS with preserved LVEF vs those with high-gradient SAS with preserved LVEF. RESULTS: We analyzed 5084 patients, of whom 413 had low-gradient SAS with preserved LVEF. For these patients, observed survival at 10, 15 and 18 years was 86.6% (95%CI, 85.3-87.8), 75% (95%CI, 72.7-77.2), and 63.5% (95%CI, 58.8-67.8). Expected survival at 10, 15 and 18 years was 90.2%, 82.1%, and 75.7%. In the matched sample, survival of patients with low-gradient SAS with preserved LVEF was similar to that of patients with high-gradient with preserved LVEF, log-rank test, P=.95; HR=1 (95%CI, 0.7-1.4; P=.95). CONCLUSIONS: There is a loss of life expectancy in patients with all types of SAS undergoing SAVR. This loss is higher in patients with left ventricular dysfunction and lower in patients with low-gradient or high-gradient aortic stenosis with preserved LVEF. The benefit of surgery is similar between these last 2 groups.

Early clinical outcomes after transaxillary versus transfemoral TAVI. Data from the Spanish TAVI registry.

INTRODUCTION AND OBJECTIVES: Transaxillary access (TXA) has become the most widely used alternative to transfemoral access (TFA) in patients undergoing transcatheter aortic valve implantation (TAVI). The aim of this study was to compare total in-hospital and 30-day mortality in patients included in the Spanish TAVI registry who were treated by TXA or TFA access. METHODS: We analyzed data from patients treated with TXA or TFA and who were included in the TAVI Spanish registry. In-hospital and 30-day events were defined according to the recommendations of the Valve Academic Research Consortium. The impact of the access route was evaluated by propensity score matching according to clinical and echocardiogram characteristics. RESULTS: A total of 6603 patients were included; 191 (2.9%) were treated via TXA and 6412 via TFA access. After adjustment (n=113 TXA group and n=3035 TFA group) device success was similar between the 2 groups (94%, TXA vs 95%, TFA; P=.95). However, compared with the TFA group, the TXA group showed a higher rate of acute myocardial infarction (OR, 5.3; 95%CI, 2.0-13.8); P=.001), renal complications (OR, 2.3; 95%CI, 1.3-4.1; P=.003), and pacemaker implantation (OR, 1.6; 95%CI, 1.01-2.6; P=.03). The TXA group also had higher in-hospital and 30-day mortality rates (OR, 2.2; 95%CI, 1.04-4.6; P=.039 and OR, 2.3; 95%CI, 1.2-4.5; P=.01, respectively). CONCLUSIONS: Compared with ATF, TXA is associated with higher total mortality, both in-hospital and at 30 days. Given these results, we believe that TXA should be considered only in those patients who are not suitable candidates for TFA.

Life expectancy after aortic valve replacement in young patients.

INTRODUCTION AND OBJECTIVES: In young patients with severe aortic stenosis, it is unknown whether their life expectancy restored after aortic valve replacement (AVR) is unknown. METHODS: We analyzed all patients aged between 50 and 65 years who underwent isolated AVR in 27 Spanish centers during an 18-year period. We compared observed and expected survival at 15 years of follow-up. We repeated all analyses for patients without complications in the postoperative period. RESULTS: A total of 5084 patients were analyzed. For the overall sample, observed survival at 10 and 15 years was 85.3% (95%CI, 84.1%-86.4%) and 73.7% (95%CI, 71.6%-75.6%), respectively. Expected survival was 90.1% and 82.1%. Cumulative relative survival for 1, 5, 10 and 15 years of follow-up was 97.4% (95%CI, 96.9%-97.9%), 96.5% (95%CI, 95.7%-97.3%), 94.7% (95%CI, 93.3%-95.9%), and 89.8% (95%CI, 87.3%-92.1%). For patients without complications, cumulative relative survival for 1, 5, 10 and 15 years was 100.3% (95%CI, 99.8%-100.5%), 98.9% (95%CI 97.6% -99.9%), 97.3% (95%CI, 94.9%-99.4%), and 91.9% (95%CI, 86.5%-96.8%). CONCLUSIONS: Life expectancy in young patients who have severe aortic stenosis and undergo AVR is lower than that of the general population. Life expectancy of individuals without complications during the postoperative period is also reduced. Therefore, baseline characteristics are likely the main factors that explain the reduction in life expectancy.

Survival in elderly patients with transcatheter aortic valve implants compared with the general population.

INTRODUCTION AND OBJECTIVES: Severe symptomatic aortic stenosis carries a very poor prognosis. Transcatheter aortic valve replacement has been demonstrated to change the natural history of the disease. However, it is not known whether the probability of survival in older patients receiving this treatment returns to a similar value to that in the general population. Our objective was to determine survival in these patients vs that in the general population. METHODS: We retrospectively analyzed the survival curves of patients older than 75 years who underwent transcatheter aortic valve implantation (TAVI) at our hospital and compared them with those in the general population of the same age, sex, and geographic region by using data from the Spanish National Institute of Statistics. RESULTS: We analyzed 526 patients. Among postoperative survivors, survival curves were similar between the 2 groups during most of the follow-up. In TAVI patients, the probability of survival at 1, 3, 5, and 8 years of follow-up was 90.58% (confidence interval [CI] 95%, 87.54-92.91), 72.51% (95%CI, 67.38-76.97), 53.23% (95%CI, 46.52-59.48), and 35.73% (95%CI, 27.72-43.80). In the reference population, these percentages were 91.93%, 75.63%, 59.6%, and 37.47%. CONCLUSIONS: Long-term survival in elderly patients undergoing TAVI is influenced by postoperative mortality. In patients surviving the postoperative period, the probability of survival returns to a similar value to that in the general population of the same age, sex, and geographical area.

Impaired Left Atrial Strain as a Predictor of New-onset Atrial Fibrillation After Aortic Valve Replacement Independently of Left Atrial Size.

INTRODUCTION AND OBJECTIVES: Left atrial dysfunction in aortic stenosis may precede atrial enlargement and predict the occurrence of atrial fibrillation (AF). To test this hypothesis, we assessed left atrial function and determined its impact on the incidence of AF after aortic valve replacement. METHODS: A total of 149 severe aortic stenosis patients (74±8.6 years, 51% men) with no prior AF were assessed using speckle-tracking echocardiography. Left atrial function was evaluated using peak atrial longitudinal strain (PALS), peak atrial contraction strain (PACS), and phasic left atrial volumes. The occurrence of AF was monitored in 114 patients from surgery until hospital discharge. RESULTS: In multiple linear regression, PALS and PACS were inversely correlated with left atrial dilation, left ventricular hypertrophy, and diastolic function. Atrial fibrillation occurred in 36 patients within a median time of 3 days [interquartile range, 1-4] after aortic valve replacement. In multiple Cox regression, PALS and PACS were independently associated with the incidence of AF (HR, 0.946; 95%CI, 0.910-0.983; P=.005 and HR, 0.932; 95%CI, 0.883-0.984; P=.011, respectively), even after further adjustment for left atrial dimensions. Both reduced PALS and PACS were associated with the incidence of AF in patients with nondilated left atria (P value for the interaction of PALS with left atrial dimensions=.013). CONCLUSIONS: In severe aortic stenosis, left atrial dysfunction predicted the incidence of postoperative AF independently of left atrial dilation, suggesting that speckle-tracking echocardiography before surgery may help in risk stratification, particularly in patients with nondilated left atria.

Relación entre el strain rate y la estructura miocárdica en la estenosis aórtica grave / Relationship between Strain Rate and Myocardial Structure in Severe Aortic Stenosis

Introducción: En la estenosis aórtica sintomática grave (EASG), la alteración del strain global longitudinal sistólico (SGLS) tendría correlación con las modificaciones de la histoarquitectura y podría identificar compromiso contráctil temprano en pacientes con fracción de eyección conservada (FEyC). Objetivo: Analizar el SGLS, el volumen de colágeno (VC), el área miocitaria (ArMi) y el compromiso contráctil en pacientes con EASG y FEyC. Material y métodos: Se incorporaron 26 pacientes con EASG y FEyC (edad 67 ± 11 años, 53% hombres). Se realizaron un estudio hemodinámico preoperatorio y una biopsia endomiocárdica intraoperatoria para determinar el VC y el ArMi. Se identificaron tres grupos de pacientes: G1, hipertrofia ventricular izquierda (HVI) compensada sin enfermedad coronaria (n = 8); G2, HVI descompensada sin enfermedad coronaria (n = 7) y G3, HVI descompensada con enfermedad coronaria (n = 11). El SGLS se normalizó por volumen sistólico, estrés meridional de fin de sístole (δ) y diámetro de fin de diástole (DFD). Resultados: G1, G2 y G3, sin diferencias en volumen sistólico, δ y DFD y con diferencias en VC (%) (G1: 4,7 ± 1,2; G2: 8,4 ± 1,2; G3: 11,0 ± 3,0; p < 0,01), ArMi (mm²) (G1: 328,7 ± 66,2; G2: 376,7 ± 21,9; G3: 385,0 ± 13,0; p = 0,01), PFDVI (mm Hg) (G1: 13,1 ± 1,5; G2: 19,0 ± 3,8; G3: 23,6 ± 5,8; p < 0,01), +dP/dt máx (mm Hg/seg / PFDVI, mm Hg) (G1: 176,4 ± 45,5; G2: 89,6 ± 20,1; G3: 113,1 ± 43,7; p < 0,01), SGLS (%) (G1: -17,9 ± 4,2; G2: -13,5 ± 2,5; G3: -13,6 ± 3; p = 0,021). El SGLS se correlacionó con VC y PFDVI y hubo tendencia con un índice de contractilidad (+dP/dt máx mm Hg/seg / PFDVI, mm Hg). Conclusiones: Las alteraciones del SGLS en pacientes con EASG y FEyC son expresión de alteraciones estructurales del miocardio relacionadas con incremento del VC, asociado con un aumento de la PFDVI y con probable falla miocárdica contráctil.

Background: In severe symptomatic aortic stenosis (SSAS) altered global longitudinal systolic strain (GLSS) would correlate with changes in myocardial histological architecture and could identify early contractile involvement in patients with preserved ejection fraction (PEF). Objective: The aim of this study was to analyze GLSS, collagen volume (CV), myocyte area (MyAr) and contractile involvement in patients with SSAS and PEF. Methods: Twenty six patients with SSAS and PEF (67±11 years old, 53% male) were included in the study. A preoperative hemodynamic study and an intraoperative endomyocardial biopsy were performed to determine CV and MyAr. Three groups of patients were identified: G1: compensated left ventricular hypertrophy (LVH) without coronary disease (n=8); G2: decompensated LVH without coronary disease (n=7) and G3: decompensated LVH with coronary disease (n=11). GLSS was normalized by stroke volume, meridional end-systolic wall stress (δ) and end-diastolic diameter (EDD). Results: No significant differences in stroke volume, δ and EDD were observed between groups G1, G2 and G3. Differences between groups were observed in: CV (%) (G1: 4.7 ± 1.2, G2: 8.4 ± 1.2, G3: 11.0 ± 3.0; p < 0.01), MyAr (mm²) (G1: 328.7 ± 66.2, G2: 376.7 ± 21.9, G3: 385.0 ± 13.0; p = 0.01), LVEDP (mm Hg) (G1: 13.1 ± 1.5, G2: 19.0 ± 3.8, G3: 23.6 ± 5.8; p < 0.01), +dP/dt max (mm Hg/sec / LVEDP, mm Hg) (G1: 176.4 ± 45.5, G2: 89.6 ± 20.1, G3: 113.1 ± 43.7; p < 0.01), and GLSS (%) (G1: -17.9 ± 4.2, G2: -13.5 ± 2.5, G3: -13.6 ± 3; p = 0.021). GLSS correlated with CV and LVEDP and it evidenced a trend to correlate with a contractility index (+dP/dt max mm Hg/s / LVEDP, mm Hg). Conclusions: Altered GLSS in patients with SSAS and PEF expresses myocardial structural changes related to increase in C V, which is associated with enhanced LVEDP and probable myocardial contractile failure.

Diagnostic ability of Physical Examination in aortic Valve stenosis / La capacidad diagnóstica del examen físico en la estenosis valvular aórtica

background: Physical examination is essential to detect aortic stenosis but there is scarce information currently available. Objectives: The goal of this study is to evaluate the diagnostic yield of physical examination, the interobserver agreement of clinical signs, and to establish a score to identify severe aortic stenosis. Methods: One-hundred patients were included in the study. Before echocardiographic evaluation, two cardiologists independently evaluated the clinical signs of the physical examination in aortic stenosis. Sensitivity, specificity, and inter-observer agreement were calculated, and the area under the curve was analyzed to develop a score for predicting severe aortic stenosis. results: The decreased intensity of the first heart sound and the crescendo-decrescendo shape of the murmur had sensitivity >90% and specificity <70%. The specificities of an absent second sound, a murmur that peaks later in systole and the presence of a parvus et tardus pulse were >95%, but the sensitivities were <50%. Inter-observer agreement was good for most criteria, except for murmur shape and intensity. The best area under the curve was achieved by the score composed of heart sounds of decreased or absent intensity, duration of the holosystolic murmur, parvus et tardus carotid pulse and a grade 3-4 systolic murmur. Conclusions: Physical examination findings have low sensitivity but good specificity. Inter-observer agreement of clinical signs of severity was moderately good. Correct identification of patients with severe aortic stenosis can be achieved using a simple score.