Valvular heart disease
Prognostic Effect of Long-Axis Left Ventricular Dysfunction and B-Type Natriuretic Peptide Levels in Asymptomatic Aortic Stenosis

https://doi.org/10.1016/j.amjcard.2009.09.043Get rights and content

In aortic stenosis (AS), the increased afterload results in progressive structural and functional changes that precede the development of symptoms. We hypothesized that the detection of abnormalities in left ventricular long-axis function could identify patients with asymptomatic AS at increased risk of events. We prospectively examined the outcome of 126 patients with asymptomatic AS who underwent a comprehensive echocardiographic examination, including tissue Doppler imaging. B-type natriuretic peptide (BNP) was measured in all patients. During a median follow-up period of 20.3 ± 17.8 months, 6 patients died, 8 developed symptoms but did not undergo surgery, and 48 underwent aortic valve replacement. On multivariate Cox regression analysis, the parameters associated with the predefined outcome were gender (p = 0.048), left atrial area index (p = 0.011), systolic annular velocity (p = 0.016), E/Ea ratio (p = 0.024), late diastolic annular velocity (p = 0.023), and BNP (p = 0.012). Using receiver operating characteristics curve analysis, a left atrial area index of ≥12.4 cm2/m2, systolic annular velocity of ≤4.5 cm/s, E/Ea ratio >13.8, late diastolic annular velocity of ≤9 cm/s, and BNP of ≥61 pg/ml were identified as the best cutoff values to predict events. In conclusion, in asymptomatic AS, tissue Doppler imaging and BNP measurements provide prognostic information beyond that from clinical and conventional echocardiographic parameters.

Section snippets

Methods

Asymptomatic patients with severe AS were prospectively screened from our echocardiographic laboratory for inclusion in the present study. All the patients met the following criteria: (1) moderate to severe AS, as defined by an aortic valve area of ≤1.2 cm2; (2) no symptoms according to a careful history taken by the referring physician; (3) normal LV ejection fraction (≥55%), as calculated by 2-dimensional echocardiography; (4) no more than mild associated cardiac valve lesions; (5) sinus

Results

The mean patient age was 67 ± 10 years (range 41 to 84). From the patient history and echocardiographic analysis findings, the suspected origin of AS was calcification of a trileaflet (n = 104), bicuspid (n = 15), rheumatic disease (commissural fusion and calcification most prominent along the edges of the cusps on echocardiography; n = 5), and undetermined (n = 2). The aortic valve area range was 0.38 to 1.2 cm2 (mean 0.82 ± 0.15), and the peak aortic pressure gradient was 77 ± 21 mm Hg. The

Discussion

The decision to perform surgery on asymptomatic patients with AS remains controversial.3, 4 The immediate risks of surgery are often weighed against the later risk of events without intervention.15 Therefore, reliable risk stratification is clinically important.16, 17, 18 In the present prospective study, we report, for the first time, the added prognostic value of tissue Doppler imaging and BNP measurement compared to the classical clinical and echocardiographic parameters in a prospective

References (29)

  • R.O. Bonow et al.

    ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

    Circulation

    (2006)
  • A. Vahanian et al.

    Guidelines on the management of valvular heart disease: the Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology

    Eur Heart J

    (2007)
  • Z. Hachicha et al.

    Paradoxical low-flow, low-gradient severe aortic stenosis despite preserved ejection fraction is associated with higher afterload and reduced survival

    Circulation

    (2007)
  • A.G. Tongue et al.

    Left ventricular longitudinal shortening in patients with aortic stenosis: relationship with symptomatic status

    J Heart Valve Dis

    (2003)
  • Cited by (0)

    View full text