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Staging Cardiac Damage in Patients With Asymptomatic Aortic Valve Stenosis
Lionel Tastet1, Christophe Tribouilloy2, Sylvestre Maréchaux3
1Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada.
Insights
A new staging system for cardiac damage in asymptomatic severe aortic stenosis (AS) effectively predicts mortality risk. This classification helps identify patients who could benefit from timely aortic valve replacement.
Area of Science:
- Cardiology
- Cardiac Surgery
- Echocardiography
Background:
- The optimal timing for intervention in patients with asymptomatic severe aortic stenosis (AS) is currently debated.
- Assessing cardiac damage beyond the aortic valve is crucial for risk stratification.
Purpose of the Study:
- To evaluate the prognostic significance of a novel staging system for cardiac damage in asymptomatic moderate to severe AS.
- To validate this staging system's ability to predict outcomes in a multicenter cohort.
Main Methods:
- Retrospective analysis of prospectively collected data from 735 asymptomatic patients with moderate to severe AS.
- Classification into stages (0-4) based on the extent of cardiac damage (left ventricular, left atrial/mitral, pulmonary/tricuspid, right ventricular/heart failure).
- Primary endpoint was all-cause mortality, analyzed using multivariable models and reclassification methods.
Main Results:
- Mortality rates increased stepwise with each stage of cardiac damage (13% in Stage 0 to 58% in Stages 3-4).
- The staging system was independently associated with excess mortality (HR 1.31 per stage increase, p=0.01).
- The staging provided incremental prognostic value beyond established clinical variables (NRI=0.34, p=0.003).
Conclusions:
- A new staging system for extra-aortic valve cardiac damage offers significant prognostic value in asymptomatic moderate to severe AS.
- This classification can aid in identifying asymptomatic AS patients who may benefit from elective aortic valve replacement.
- The findings support the use of this staging system for improved clinical decision-making.
Background:
The optimal timing of intervention in patients with asymptomatic severe aortic stenosis (AS) remains controversial.
Objectives:
This multicenter study sought to test and validate the prognostic value of the staging of cardiac damage in patients with asymptomatic moderate to severe AS.
Methods:
This study retrospectively analyzed the clinical, Doppler echocardiographic, and outcome data that were prospectively collected in 735 asymptomatic patients (71 ± 14 years of age; 60% men) with at least moderate AS (aortic valve area <1.5 cm2) and preserved left ventricular ejection fraction (≥50%) followed in the heart valve clinics of 4 high-volume centers. Patients were classified according to the following staging classification: no cardiac damage associated with the valve stenosis (Stage 0), left ventricular damage (Stage 1), left atrial or mitral valve damage (Stage 2), pulmonary vasculature or tricuspid valve damage (Stage 3), or right ventricular damage or subclinical heart failure (Stage 4). The primary endpoint was all-cause mortality.
Results:
At baseline, 89 (12%) patients were classified in Stage 0, 200 (27%) in Stage 1, 341 (46%) in Stage 2, and 105 (14%) in Stage 3 or 4. Median follow-up was 2.6 years (interquartile range: 1.1 to 5.2 years). There was a stepwise increase in mortality rates according to staging: 13% in Stage 0, 25% in Stage 1, 44% in Stage 2, and 58% in Stages 3 to 4 (p < 0.0001). The staging was significantly associated with excess mortality in multivariable analysis adjusted for aortic valve replacement as a time-dependent variable (hazard ratio: 1.31 per each increase in stage; 95% CI: 1.06 to 1.61; p = 0.01), and showed incremental value to several clinical variables (net reclassification index = 0.34; p = 0.003).
Conclusions:
The new staging system characterizing the extra-aortic valve cardiac damage provides incremental prognostic value in patients with asymptomatic moderate to severe AS. This staging classification may be helpful to identify asymptomatic AS patients who may benefit from elective aortic valve replacement.
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