Key result
Extra-aortic cardiac damage staging linked to ~31% higher mortality per stage in asymptomatic moderate to severe AS.
Why the study?
The optimal timing of intervention in asymptomatic severe aortic stenosis remains controversial, and the prognostic value of staging cardiac damage in asymptomatic moderate to severe AS needed testing and validation.
Does a staging system characterizing extra-aortic valve cardiac damage predict all-cause mortality in asymptomatic patients with moderate to severe aortic stenosis?
Cohort (n=735)
Yes
Does a staging system characterizing extra-aortic valve cardiac damage predict all-cause mortality in asymptomatic patients with moderate to severe aortic stenosis?
A novel echocardiographic staging system characterizing extra-aortic valve cardiac damage provides incremental prognostic value for all-cause mortality in asymptomatic patients with moderate to severe aortic stenosis.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“The validation of this concept of staging cardiac damage within a population with very severe AS with no symptoms is extremely important. We still are debating what to do with these patients, and the ongoing EARLY-TAVR trial will give us more information to help with that.”
“Aortic stenosis is a sneaky disease. There's a lot of damage that develops silently, and patients who are asymptomatic are falsely reassured that they're fine.”
“As you're waiting, things are happening, and those things are maladaptive and they're not reversible. We saw some of the patients improve, but the majority stay the same or even get worse, even after the aortic valve replacement. So we have to be preemptive, we have to be thinking ahead, and we have to think of AS as not just a hemodynamic disease at the valve level, but a cardiac disease. And [we need to] use both hemodynamics and staging to make decisions about when to treat patients, not just symptoms.”
May refine risk stratification in asymptomatic AS; extends staging concept but leaves management implications open pending trials.
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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Tastet et al. (2019) conducted a cohort in Asymptomatic moderate to severe aortic stenosis (n=735). Staging of cardiac damage was evaluated on All-cause mortality (HR 1.31 per stage increase, 95% CI 1.06 to 1.61, p=0.01). A staging system characterizing extra-aortic valve cardiac damage was significantly associated with all-cause mortality in asymptomatic moderate to severe AS (HR 1.31 per stage increase; P=0.01).
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