Transvalvular Flow, Sex, and Survival After Valve Replacement Surgery in Patients With Severe Aortic Stenosis
The respective impacts of transvalvular flow, gradient, sex, and their interactions on mortality in patients with severe aortic stenosis undergoing surgical aortic valve replacement (AVR) are unknown. This study sought to compare the impact of pre-operative flow-gradient patterns on mortality after...
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| Veröffentlicht in: | Journal of the American College of Cardiology 2020-04, Vol.75 (16), p.1897-1909 |
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| creator | Guzzetti, Ezequiel Poulin, Anthony Annabi, Mohamed-Salah Zhang, Bin Kalavrouziotis, Dimitri Couture, Christian Dagenais, François Pibarot, Philippe Clavel, Marie-Annick |
| description | The respective impacts of transvalvular flow, gradient, sex, and their interactions on mortality in patients with severe aortic stenosis undergoing surgical aortic valve replacement (AVR) are unknown.
This study sought to compare the impact of pre-operative flow-gradient patterns on mortality after AVR and to examine whether there are sex differences.
This study analyzed clinical, echocardiographic, and outcome data prospectively collected in 1,490 patients (544 women [37%]), with severe aortic stenosis and preserved left ventricular ejection fraction who underwent AVR.
In this cohort, 601 patients (40%) had normal flow (NF) with high gradient (HG), 405 (27%) NF with low gradient (LG), 246 (17%) paradoxical low flow (LF)/HG, and 238 (16%) LF/LG. During a median follow-up of 2.42 years (interquartile range: 1.04 to 4.29 years), 167 patients died. Patients with LF/HG exhibited the highest mortality after AVR (hazard ratio [HR]: 2.01; 95% confidence interval [CI]: 1.33 to 3.03; p |
| doi_str_mv | 10.1016/j.jacc.2020.02.065 |
| format | Article |
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This study sought to compare the impact of pre-operative flow-gradient patterns on mortality after AVR and to examine whether there are sex differences.
This study analyzed clinical, echocardiographic, and outcome data prospectively collected in 1,490 patients (544 women [37%]), with severe aortic stenosis and preserved left ventricular ejection fraction who underwent AVR.
In this cohort, 601 patients (40%) had normal flow (NF) with high gradient (HG), 405 (27%) NF with low gradient (LG), 246 (17%) paradoxical low flow (LF)/HG, and 238 (16%) LF/LG. During a median follow-up of 2.42 years (interquartile range: 1.04 to 4.29 years), 167 patients died. Patients with LF/HG exhibited the highest mortality after AVR (hazard ratio [HR]: 2.01; 95% confidence interval [CI]: 1.33 to 3.03; p < 0.01), which remained significant after multivariate adjustment (HR: 1.96; 95% CI: 1.29 to 2.98; p < 0.01). Both LF/LG and NF/LG patients had comparable outcome to NF/HG (p ≥ 0.47). Optimal thresholds of stroke volume index were obtained for men (40 ml/m2) and women (32 ml/m2). Using these sex-specific cutpoints, paradoxical LF was independently associated with increased mortality in both women (adjusted HR: 2.05; 95% CI: 1.21 to 3.47; p < 0.01) and men (adjusted HR: 1.54; 95% CI: 1.02 to 2.32; p = 0.042), whereas guidelines’ threshold (35 ml/m2) does not.
Paradoxical LF/HG was associated with higher mortality following AVR, suggesting that a reduced flow is a marker of disease severity even in patients with HG aortic stenosis. Early surgical AVR (i.e., before gradient attains 40 mm Hg) might be preferable in these patients. Furthermore, the use of sex-specific thresholds (<40 ml/m2 for men and <32 ml/m2 for women) to define low-flow outperforms the guidelines’ threshold of 35 ml/m2 in risk stratification after AVR.
[Display omitted]</description><identifier>ISSN: 0735-1097</identifier><identifier>EISSN: 1558-3597</identifier><identifier>DOI: 10.1016/j.jacc.2020.02.065</identifier><identifier>PMID: 32327100</identifier><language>eng</language><publisher>United States: Elsevier Inc</publisher><subject>Aged ; Aortic Valve - diagnostic imaging ; Aortic Valve - physiopathology ; Aortic Valve - surgery ; Aortic Valve Stenosis - diagnosis ; Aortic Valve Stenosis - physiopathology ; Aortic Valve Stenosis - surgery ; calcific aortic stenosis ; Canada ; Echocardiography, Doppler, Color - methods ; Echocardiography, Doppler, Color - statistics & numerical data ; Female ; Heart Valve Prosthesis Implantation - adverse effects ; Heart Valve Prosthesis Implantation - methods ; Heart Valve Prosthesis Implantation - statistics & numerical data ; Humans ; Male ; Outcome Assessment, Health Care ; paradoxical low flow ; Postoperative Complications - diagnosis ; Postoperative Complications - mortality ; Preoperative Care - methods ; Preoperative Care - statistics & numerical data ; Risk Assessment - methods ; Severity of Illness Index ; sex differences ; Sex Factors ; Stroke Volume ; surgical aortic valve replacement ; survival</subject><ispartof>Journal of the American College of Cardiology, 2020-04, Vol.75 (16), p.1897-1909</ispartof><rights>2020 American College of Cardiology Foundation</rights><rights>Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c356t-11957cce86fb5beec6cbef5a777a8c9f96b159326822f21fcfcd0d2c519ad1423</citedby><cites>FETCH-LOGICAL-c356t-11957cce86fb5beec6cbef5a777a8c9f96b159326822f21fcfcd0d2c519ad1423</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktohtml>$$Uhttps://dx.doi.org/10.1016/j.jacc.2020.02.065$$EHTML$$P50$$Gelsevier$$H</linktohtml><link.rule.ids>314,780,784,3550,27924,27925,45995</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/32327100$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Guzzetti, Ezequiel</creatorcontrib><creatorcontrib>Poulin, Anthony</creatorcontrib><creatorcontrib>Annabi, Mohamed-Salah</creatorcontrib><creatorcontrib>Zhang, Bin</creatorcontrib><creatorcontrib>Kalavrouziotis, Dimitri</creatorcontrib><creatorcontrib>Couture, Christian</creatorcontrib><creatorcontrib>Dagenais, François</creatorcontrib><creatorcontrib>Pibarot, Philippe</creatorcontrib><creatorcontrib>Clavel, Marie-Annick</creatorcontrib><title>Transvalvular Flow, Sex, and Survival After Valve Replacement Surgery in Patients With Severe Aortic Stenosis</title><title>Journal of the American College of Cardiology</title><addtitle>J Am Coll Cardiol</addtitle><description>The respective impacts of transvalvular flow, gradient, sex, and their interactions on mortality in patients with severe aortic stenosis undergoing surgical aortic valve replacement (AVR) are unknown.
This study sought to compare the impact of pre-operative flow-gradient patterns on mortality after AVR and to examine whether there are sex differences.
This study analyzed clinical, echocardiographic, and outcome data prospectively collected in 1,490 patients (544 women [37%]), with severe aortic stenosis and preserved left ventricular ejection fraction who underwent AVR.
In this cohort, 601 patients (40%) had normal flow (NF) with high gradient (HG), 405 (27%) NF with low gradient (LG), 246 (17%) paradoxical low flow (LF)/HG, and 238 (16%) LF/LG. During a median follow-up of 2.42 years (interquartile range: 1.04 to 4.29 years), 167 patients died. Patients with LF/HG exhibited the highest mortality after AVR (hazard ratio [HR]: 2.01; 95% confidence interval [CI]: 1.33 to 3.03; p < 0.01), which remained significant after multivariate adjustment (HR: 1.96; 95% CI: 1.29 to 2.98; p < 0.01). Both LF/LG and NF/LG patients had comparable outcome to NF/HG (p ≥ 0.47). Optimal thresholds of stroke volume index were obtained for men (40 ml/m2) and women (32 ml/m2). Using these sex-specific cutpoints, paradoxical LF was independently associated with increased mortality in both women (adjusted HR: 2.05; 95% CI: 1.21 to 3.47; p < 0.01) and men (adjusted HR: 1.54; 95% CI: 1.02 to 2.32; p = 0.042), whereas guidelines’ threshold (35 ml/m2) does not.
Paradoxical LF/HG was associated with higher mortality following AVR, suggesting that a reduced flow is a marker of disease severity even in patients with HG aortic stenosis. Early surgical AVR (i.e., before gradient attains 40 mm Hg) might be preferable in these patients. Furthermore, the use of sex-specific thresholds (<40 ml/m2 for men and <32 ml/m2 for women) to define low-flow outperforms the guidelines’ threshold of 35 ml/m2 in risk stratification after AVR.
[Display omitted]</description><subject>Aged</subject><subject>Aortic Valve - diagnostic imaging</subject><subject>Aortic Valve - physiopathology</subject><subject>Aortic Valve - surgery</subject><subject>Aortic Valve Stenosis - diagnosis</subject><subject>Aortic Valve Stenosis - physiopathology</subject><subject>Aortic Valve Stenosis - surgery</subject><subject>calcific aortic stenosis</subject><subject>Canada</subject><subject>Echocardiography, Doppler, Color - methods</subject><subject>Echocardiography, Doppler, Color - statistics & numerical data</subject><subject>Female</subject><subject>Heart Valve Prosthesis Implantation - adverse effects</subject><subject>Heart Valve Prosthesis Implantation - methods</subject><subject>Heart Valve Prosthesis Implantation - statistics & numerical data</subject><subject>Humans</subject><subject>Male</subject><subject>Outcome Assessment, Health Care</subject><subject>paradoxical low flow</subject><subject>Postoperative Complications - diagnosis</subject><subject>Postoperative Complications - mortality</subject><subject>Preoperative Care - methods</subject><subject>Preoperative Care - statistics & numerical data</subject><subject>Risk Assessment - methods</subject><subject>Severity of Illness Index</subject><subject>sex differences</subject><subject>Sex Factors</subject><subject>Stroke Volume</subject><subject>surgical aortic valve replacement</subject><subject>survival</subject><issn>0735-1097</issn><issn>1558-3597</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2020</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNp9kE1v1DAQhi0EapfSP8Ch8pFDk9pOndhSL6uqpZUqFbEFjpYzGYNX-VhsJ9B_j1dbOHIaaeZ5X2keQt5zVnLG64ttubUApWCClUyUrJavyIpLqYpK6uY1WbGmkgVnujkmb2PcMsZqxfUROa5EJRrO2IoMT8GOcbH9Mvc20Nt--nVON_j7nNqxo5s5LD4f6dolDPRrxpB-xl1vAQcc0x74juGZ-pF-ssnnVaTffPqRKxYMSNdTSB7oJuE4RR_fkTfO9hFPX-YJ-XJ783R9Vzw8fry_Xj8UUMk6FZxr2QCgql0rW0SooUUnbdM0VoF2um651JWolRBOcAcOOtYJkFzbjl-K6oR8OPTuwvRzxpjM4CNg39sRpzkaUelLpSRTKqPigEKYYgzozC74wYZnw5nZazZbs9ds9poNEyZrzqGzl_65HbD7F_nrNQNXBwDzl4vHYCJkO4CdDwjJdJP_X_8faouPXw</recordid><startdate>20200428</startdate><enddate>20200428</enddate><creator>Guzzetti, Ezequiel</creator><creator>Poulin, Anthony</creator><creator>Annabi, Mohamed-Salah</creator><creator>Zhang, Bin</creator><creator>Kalavrouziotis, Dimitri</creator><creator>Couture, Christian</creator><creator>Dagenais, François</creator><creator>Pibarot, Philippe</creator><creator>Clavel, Marie-Annick</creator><general>Elsevier Inc</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope></search><sort><creationdate>20200428</creationdate><title>Transvalvular Flow, Sex, and Survival After Valve Replacement Surgery in Patients With Severe Aortic Stenosis</title><author>Guzzetti, Ezequiel ; 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This study sought to compare the impact of pre-operative flow-gradient patterns on mortality after AVR and to examine whether there are sex differences.
This study analyzed clinical, echocardiographic, and outcome data prospectively collected in 1,490 patients (544 women [37%]), with severe aortic stenosis and preserved left ventricular ejection fraction who underwent AVR.
In this cohort, 601 patients (40%) had normal flow (NF) with high gradient (HG), 405 (27%) NF with low gradient (LG), 246 (17%) paradoxical low flow (LF)/HG, and 238 (16%) LF/LG. During a median follow-up of 2.42 years (interquartile range: 1.04 to 4.29 years), 167 patients died. Patients with LF/HG exhibited the highest mortality after AVR (hazard ratio [HR]: 2.01; 95% confidence interval [CI]: 1.33 to 3.03; p < 0.01), which remained significant after multivariate adjustment (HR: 1.96; 95% CI: 1.29 to 2.98; p < 0.01). Both LF/LG and NF/LG patients had comparable outcome to NF/HG (p ≥ 0.47). Optimal thresholds of stroke volume index were obtained for men (40 ml/m2) and women (32 ml/m2). Using these sex-specific cutpoints, paradoxical LF was independently associated with increased mortality in both women (adjusted HR: 2.05; 95% CI: 1.21 to 3.47; p < 0.01) and men (adjusted HR: 1.54; 95% CI: 1.02 to 2.32; p = 0.042), whereas guidelines’ threshold (35 ml/m2) does not.
Paradoxical LF/HG was associated with higher mortality following AVR, suggesting that a reduced flow is a marker of disease severity even in patients with HG aortic stenosis. Early surgical AVR (i.e., before gradient attains 40 mm Hg) might be preferable in these patients. Furthermore, the use of sex-specific thresholds (<40 ml/m2 for men and <32 ml/m2 for women) to define low-flow outperforms the guidelines’ threshold of 35 ml/m2 in risk stratification after AVR.
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| subjects | Aged Aortic Valve - diagnostic imaging Aortic Valve - physiopathology Aortic Valve - surgery Aortic Valve Stenosis - diagnosis Aortic Valve Stenosis - physiopathology Aortic Valve Stenosis - surgery calcific aortic stenosis Canada Echocardiography, Doppler, Color - methods Echocardiography, Doppler, Color - statistics & numerical data Female Heart Valve Prosthesis Implantation - adverse effects Heart Valve Prosthesis Implantation - methods Heart Valve Prosthesis Implantation - statistics & numerical data Humans Male Outcome Assessment, Health Care paradoxical low flow Postoperative Complications - diagnosis Postoperative Complications - mortality Preoperative Care - methods Preoperative Care - statistics & numerical data Risk Assessment - methods Severity of Illness Index sex differences Sex Factors Stroke Volume surgical aortic valve replacement survival |
| title | Transvalvular Flow, Sex, and Survival After Valve Replacement Surgery in Patients With Severe Aortic Stenosis |
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