Key result
Worsening extravalvular cardiac damage one year post-AVR is linked to ~95% higher two-year mortality.
Why the study?
The impact of aortic valve replacement on the progression or regression of extra-valvular cardiac damage and its association with subsequent prognosis was unknown.
Does the 1-year change in extravalvular cardiac damage post-aortic valve replacement predict 2-year mortality and heart failure hospitalization in patients undergoing AVR?
Cohort (n=1,974)
Does the 1-year change in extravalvular cardiac damage post-aortic valve replacement predict 2-year mortality and heart failure hospitalization in patients undergoing AVR?
Hazard Ratio: 1.95
p-value: p=0.023
The evolution of extravalvular cardiac damage at 1-year post-AVR is strongly associated with 2-year mortality and heart failure hospitalization, suggesting that earlier intervention prior to irreversible damage may improve prognosis.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“People will often say, 'It's only moderate AS,' but moderate AS is bad. When you look at the valves, they're very calcified, they're restricted. It puts an extra load, more pressure on the left ventricle. Even mild aortic stenosis can be seen as bad especially since it progresses so fast. To have mild or moderate AS is not the same as having no aortic stenosis at all. I think we need to reevaluate the spectrum of AS severity because we've been very complacent in the past.”
“The wait is over. It's time to change the guidelines. It's time to talk with our patients and to plan accordingly in a civilized way, and not wait until the patient falls off the cliff and then say, 'oh, let me help you.'”
May aid post-AVR risk stratification; hypothesis-generating before serial staging alters management.
BACKGROUND The impact of aortic valve replacement (AVR) on progression/regression of extra-valvular cardiac damage and its association with subsequent prognosis is unknown. OBJECTIVES To describe evolution of cardiac damage post-AVR and its association with outcomes. METHODS Patients undergoing transcatheter or surgical AVR from the PARTNER 2 and 3 trials were pooled and classified by cardiac damage stage at baseline and 1-year (Stage 0, no damage; Stage 1, left ventricular damage; Stage 2, left atrial or mitral valve damage; Stage 3, pulmonary vasculature or tricuspid valve damage; Stage 4, right ventricular damage). Proportional hazards models determined association between change in cardiac damage post-AVR and 2-year outcomes. RESULTS Among 1974 patients, 121 (6.1%) were Stage 0, 287 (14.5%) Stage 1, 1014 (51.4%) Stage 2, 412 (20.9%) Stage 3, and 140 (7.1%) Stage 4 pre-AVR. Two-year mortality was associated with extent of cardiac damage at baseline and 1-year. Compared with baseline, cardiac damage improved in ∼15%, remained unchanged in ∼60%, and worsened in ∼25% of patients at 1-year. One-year change in cardiac damage stage was independently associated with mortality (adjHR for improvement=0.49; no change=1.0; worsening=1.95; p=0.023) and composite of death or heart failure hospitalization (adjHR for improvement=0.60; no change=1.0; worsening=2.25; p<0.001) at 2 years. CONCLUSION In patients undergoing AVR, extent of extravalvular cardiac damage at baseline and its change at 1-year have important prognostic implications. These findings suggest that earlier detection of AS and intervention prior to development of irreversible cardiac damage may improve global cardiac function and prognosis.
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Généreux et al. (2022) conducted a cohort in Aortic stenosis (n=1,974). Change in cardiac damage stage post-AVR vs. No change in cardiac damage stage was evaluated on Mortality at 2 years (adjHR 1.95, p=0.023). Worsening of extravalvular cardiac damage at 1-year post-aortic valve replacement was associated with increased 2-year mortality compared to no change (adjHR 1.95; p=0.023).
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