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Fusion of Doppler echocardiography and computed tomography in patients who underwent transcatheter aortic valve implantation (TAVI) for low-gradient, severe aortic stenosis (AS) (<40 mm Hg) resulted in the reclassification of 35% of patients to moderate AS.
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The composite endpoint of all-cause mortality and heart failure rehospitalisations post-TAVI was similar in patients reclassified to moderate AS and patients with severe AS.
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Patients reclassified to moderate AS showed similar improvements in New York Heart Association class to those with severe AS.
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Non-cardiac death was more frequent in patients reclassified to moderate AS with LVEF <50% versus LVEF ≥50%.
Introduction
Methods
Patient population
Transthoracic echocardiography
Multi-slice computed tomography
Fusion imaging
Statistical analysis
Results
Baseline characteristics
Overall cohort
Overall cohort | |
---|---|
n = 359 | |
Demographics | |
Age (years), median (IQR) | 80 (75–84) |
Male, n (%) | 206 (57) |
Height (cm), median (IQR) | 168 (162–175) |
Weight (kg), mean ± SD | 76 ± 14 |
Body mass index (kg/m2), median (IQR) | 26 (24–29) |
Body surface area (m2), median (IQR) | 1.9 (1.7–2.0) |
Cardiac risk factors | |
Diabetes mellitus, n (%) | 125 (35) |
Hypertension, n (%) | 271 (76) |
Medical history | |
Previous cerebrovascular accident or transient ischaemic attack, n (%) | 75 (21) |
Previous myocardial infarction, n (%) | 107 (30) |
Previous coronary artery bypass graft surgery, n (%) | 110 (31) |
Previous percutaneous coronary intervention, n (%) | 157 (44) |
Permanent pacemaker, n (%) | 49 (14) |
Peripheral vascular disease, n (%) | 187 (52) |
Chronic obstructive pulmonary disease, n (%) | 104 (29) |
Pulmonary hypertension, n (%) | 60 (17) |
Atrial fibrillation, n (%) | 121 (34) |
New York Heart Association class ≥III, n (%) | 269 (75) |
Echocardiography | |
Left ventricular ejection fraction (%), mean ± SD | 46 ± 15 |
Peak velocity (m/s), median (IQR) | 3.5 (3.2–3.9) |
Peak gradient (mm Hg), median (IQR) | 49 (41–61) |
Mean gradient (mm Hg), median (IQR) | 29 (24–35) |
Aortic valve area (cm2), median (IQR) | 0.8 (0.7–0.9) |
Indexed aortic valve area (cm2/m2), median (IQR) | 0.4 (0.4–0.5) |
LVOT VTI, median (IQR) | 18 (15–21) |
Aortic valve VTI, mean ± SD | 79 ± 15 |
Stroke volume index, median (IQR) | 32 (26–40) |
Mitral regurgitation ≥ moderate, n (%) | 84 (23) |
Aortic regurgitation ≥ moderate, n (%) | 51 (14) |
Multi-slice computed tomography | |
Annulus | |
– Minimum diameter (mm), median (IQR) | 22 (21–24) |
– Maximum diameter (mm), median (IQR) | 27 (26–29) |
– Mean diameter (mm), median (IQR) | 25 (23–26) |
– Area (mm2), median (IQR) | 464 (413–525) |
– Perimeter (mm), median (IQR) | 78 (74–84) |
– Aortic root calcification ≥ moderate, n (%) | 259 (72) |
Left ventricular outflow tract | |
– Area (mm2), median (IQR) | 448 (389–515) |
– LVOT calcification ≥ moderate, n (%) | 46 (13) |
Risk score | |
– Logistic EuroSCORE, median (IQR) | 16 (10–24) |
Fusion reclassification
Overall cohort | Patients reclassified to severe AS | Patients reclassified to moderate AS | p-value | |
---|---|---|---|---|
n = 359 | n = 233 | n = 126 | ||
Fusion aortic valve area (cm2), median (IQR) | 1.02 (0.87–1.21) | 0.92 (0.79–1.04) | 1.28 (1.16–1.46) | <0.001 |
Indexed fusion aortic valve area (cm2/m2), median (IQR) | 0.54 (0.47–0.65) | 0.49 (0.43–0.54) | 0.70 (0.65–0.80) | <0.001 |
Demographics | ||||
Age (years), median (IQR) | 80 (75–84) | 81 (76–84) | 80 (75–84) | 0.81 |
Male, n (%) | 206 (57) | 133 (57) | 73 (58) | 0.88 |
Height (cm), median (IQR) | 168 (162–175) | 170 (163–176) | 167 (160–174) | 0.060 |
Weight (kg), mean ± SD | 76 ± 14 | 78 ± 13 | 72 ± 13 | <0.001 |
Body mass index (kg/m2), median (IQR) | 26 (24–29) | 27 (24–30) | 25 (23–28) | <0.001 |
Body surface area (m2), median (IQR) | 1.9 (1.7–2.0) | 1.9 (1.8–2.0) | 1.8 (1.7–1.9) | <0.001 |
Cardiac risk factors | ||||
Diabetes mellitus, n (%) | 125 (35) | 89 (38) | 36 (29) | 0.068 |
Hypertension, n (%) | 271 (76) | 171 (73) | 100 (79) | 0.21 |
Medical history | ||||
Previous cerebrovascular accident or transient ischaemic attack, n (%) | 75 (21) | 52 (22) | 23 (18) | 0.37 |
Previous myocardial infarction, n (%) | 107 (30) | 57 (25) | 50 (40) | 0.003 |
Previous coronary artery bypass graft surgery, n (%) | 110 (31) | 64 (28) | 46 (37) | 0.081 |
Previous percutaneous coronary intervention, n (%) | 157 (44) | 100 (43) | 57 (45) | 0.67 |
Permanent pacemaker, n (%) | 49 (14) | 33 (14) | 16 (13) | 0.70 |
Peripheral vascular disease, n (%) | 187 (52) | 122 (52) | 65 (52) | 0.89 |
Chronic obstructive pulmonary disease, n (%) | 104 (29) | 64 (28) | 40 (32) | 0.37 |
Pulmonary hypertension, n (%) | 60 (17) | 34 (15) | 26 (21) | 0.14 |
Atrial fibrillation, n (%) | 121 (34) | 76 (33) | 45 (36) | 0.55 |
New York Heart Association class ≥III, n (%) | 269 (75) | 181 (78) | 88 (70) | 0.087 |
Echocardiography | ||||
Left ventricular ejection fraction (%), mean ± SD | 46 ± 15 | 46 ± 15 | 47 ± 16 | 0.39 |
Peak velocity (m/s), median (IQR) | 3.5 (3.2–3.9) | 3.7 (3.4–3.9) | 3.3 (3.0–3.5) | <0.001 |
Peak gradient (mm Hg), median (IQR) | 49 (41–61) | 55 (46–61) | 43 (35–51) | <0.001 |
Mean gradient (mm Hg), median (IQR) | 29 (24–35) | 32 (27–36) | 25 (19–30) | <0.001 |
Aortic valve area (cm2), median (IQR) | 0.8 (0.7–0.9) | 0.7 (0.6–0.8) | 0.9 (0.8–1.0) | <0.001 |
Indexed aortic valve area, median (IQR) | 0.4 (0.4–0.5) | 0.4 (0.3–0.4) | 0.5 (0.5–0.6) | <0.001 |
LVOT VTI, median (IQR) | 18 (15–21) | 17 (16–21) | 19 (16–22) | 0.002 |
Aortic valve VTI, mean ± SD | 79 ± 15 | 83 ± 14 | 72 ± 14 | <0.001 |
Stroke volume index, median (IQR) | 32 (26–40) | 31 (26–38) | 36 (28–43) | <0.001 |
Mitral regurgitation grade ≥II, n (%) | 84 (23) | 47 (20) | 37 (29) | 0.050 |
Aortic regurgitation grade ≥II, n (%) | 51 (14) | 30 (13) | 21 (17) | 0.33 |
Multi-slice computed tomography | ||||
Annulus | ||||
– Minimum diameter (mm), median (IQR) | 22 (21–24) | 22 (20–23) | 23 (21–24) | <0.001 |
– Maximum diameter (mm), median (IQR) | 27 (26–29) | 27 (25–29) | 28 (26–30) | 0.003 |
– Mean diameter (mm), median (IQR) | 25 (23–26) | 25 (23–26) | 25 (24–27) | 0.001 |
– Area (mm2), median (IQR) | 464 (413–525) | 454 (402–516) | 483 (437–546) | 0.002 |
– Perimeter (mm), median (IQR) | 78 (74–84) | 77 (72–83) | 80 (76–85) | 0.001 |
– Aortic root calcification ≥ moderate, n (%) | 259 (72) | 166 (71) | 93 (74) | 0.61 |
– Calcium score (Agatston), median (IQR) | 2121 (1320–3140) | 2282 (1516–3345) | 1833 (1184–2904) | 0.002 |
Left ventricular outflow tract | ||||
– Area (mm2), median (IQR) | 448 (389–515) | 432 (373–499) | 467 (424–561) | <0.001 |
– LVOT calcification ≥ moderate, n (%) | 46 (13) | 34 (15) | 12 (10) | 0.17 |
Risk score | ||||
Logistic EuroSCORE, median (IQR) | 16 (10–24) | 15 (10–22) | 19 (11–27) | 0.005 |
Clinical outcome
Overall cohort
Reclassification of AS and outcome
Baseline | 1 year post-TAVI | Difference, mean (95% CI) | p-value | |
---|---|---|---|---|
Left ventricular ejection fraction in the overall cohort (%), mean ± SD | 46.40 ± 15.13 | 46.44 ± 12.94 | 0.040 (−1.67;1.75) | 0.96 |
Left ventricular ejection fraction in severe AS (%), mean ± SD | 45.42 ± 14.56 | 46.42 ± 12.59 | 1.00 (−1.14; 3.14) | 0.36 |
Left ventricular ejection fraction in reclassified moderate AS (%), mean ± SD | 48.21 ± 16.07 | 46.47 ± 13.66 | 1.74 (−4.62; 1.13) | 0.23 |