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Echocardiographic assessment of diastolic dysfunction in elderly patients with severe aortic stenosis before and
Hatice Akay Caglayan1,2, Didrik Kjønås3, Siri Malm4
1Department of Cardiology, Division of Cardiothoracic and Respiratory Medicine, University Hospital of North Norway, 9038, Tromsø, Norway.
Insights
Echocardiography guidelines for diastolic dysfunction in aortic stenosis (AS) need adjustment. Modified thresholds improve the detection of elevated filling pressures, indicated by N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels.
Area of Science:
- Cardiology
- Medical Imaging
- Echocardiography
Background:
- Current American Society of Echocardiography (ASE) and European Association of Cardiovascular Imaging (EACVI) guidelines for diastolic dysfunction do not adequately address high filling pressures in patients with aortic stenosis (AS).
- Existing research suggests age-independent diastolic features specific to AS.
- N-terminal prohormone of brain natriuretic peptide (NT-proBNP) serves as a biomarker for elevated filling pressures.
Purpose of the Study:
- To determine the disease-specific range and distribution of diastolic functional parameters in AS patients.
- To evaluate the ability of these parameters to identify elevated NT-proBNP levels, indicating high filling pressures.
Main Methods:
- 169 patients undergoing surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) were prospectively enrolled.
- Resting echocardiography included Doppler of mitral inflow, pulmonary venous flow, tricuspid regurgitant flow, tissue Doppler, and left atrial volume index (LAVI).
- Echocardiography and NT-proBNP levels were assessed pre- and post-procedure (6 and 12 months).
Main Results:
- Pre- and postoperative echocardiographic and NT-proBNP values showed persistent diastolic dysfunction and elevated filling pressures.
- The standard ASE/EACVI scoring detected elevated NT-proBNP with only 25% specificity.
- Adjusting thresholds (e.g., PAP ≥ 40 mmHg, E velocity ≥ 100 cm/s, E/septal e' ≥ 20) significantly improved specificity (>85%) for detecting NT-proBNP levels ≥ 500 ng/L.
Conclusions:
- Diastolic echocardiographic parameters in AS indicate persistent impaired relaxation and elevated filling pressures, which improve only modestly after valve replacement.
- The 2016 ASE/EACVI recommendations are insufficient for reliably detecting elevated NT-proBNP in AS patients.
- Modified echocardiographic thresholds enhance the diagnostic accuracy for elevated filling pressures in AS.
Background:
The 2016 guidelines of the American Society of Echocardiography (ASE) and European Association of Cardiovascular Imaging (EACVI) for evaluation of left ventricular (LV) diastolic dysfunction by Doppler flow and tissue Doppler- echocardiography do not adjust assessment of high filling pressures for patients with aortic stenosis (AS). However, most of the studies on this patient group indicate age independent specific diastolic features in AS. The aim of this study is to identify disease-specific range and distribution of diastolic functional parameters and their ability to identify high N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels as a marker for high filling pressures.
Methods:
In this study, 169 patients who underwent surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) were prospectively enrolled. Resting echocardiography was performed including Doppler of the mitral inflow, pulmonary venous flow, tricuspid regurgitant flow and tissue Doppler in the mitral ring and indexed volume-estimates of the left atrium (LAVI). Echocardiography, and NT-proBNP levels were assessed before TAVR/SAVR and at two postoperative visits at 6 and 12 months.
Results:
Pre- and postoperative values were septal e'; 5.1 ± 3.9, 5.2 ± 1.6 cm/s; lateral e' 6.3 ± 2.1; 7.7 ± 2.7 cm/s; E/e'19 ± 8; 16 ± 7 cm/s; E velocity 96 ± 32; 95 ± 32 cm/s; LAVI 39 ± 8; 36 ± 8 ml/m2, pulmonary artery pressure (PAP) 39 ± 8; 36 ± 8 mmHg, respectively. The scoring recommended by ASE/EACVI detected elevated NT pro-BNP with a specificity of 25%. Adjusting thresholds towards PAP ≥ 40 mmHg, E velocity ≥ 100 cm/s, E deceleration time < 220 ms, and E/septal e' ≥ 20 or septal e' < 5.0 cm/s increased prediction of NT-proBNP levels ≥500 ng/L with substantially improved specificity (> 85%).
Conclusion:
Diastolic echocardiographic parameters in AS indicate persistent impaired relaxation and NT-proBNP indicate elevated filling pressures in most of the patients, improving only modestly 6-12 months after TAVR and SAVR. Applying the 2016 ASE/EACVI recommendations for detection of elevated filling pressures to patients with AS, elevated NT pro-BNP levels could not be reliably detected. However, adjusting thresholds of the echocardiographic parameters increased specificities to useful diagnostic levels.
Trial Registration:
The study was prospectively approved by the regional ethical committee, REK North with the registration number: REK 2010/397-10 .
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