Prognostic Value of Aortic Valve Area Index in Asymptomatic Patients With Severe Aortic Stenosis

doi:10.1016/j.amjcard.2012.02.056

The American Journal of Cardiology

Volume 110, Issue 1, 1 July 2012, Pages 93-97

https://doi.org/10.1016/j.amjcard.2012.02.056 Get rights and content

Recently, an aortic valve area (AVA) index (AVAI) <0.6 cm²/m² was proposed as an indicator of severe aortic stenosis. The purpose of the present study was to clarify the prognostic value of the AVAI. We identified 103 consecutive asymptomatic patients (mean age 72 ± 11 years) with severe aortic stenosis, defined by an AVA of <1.0 cm², who had not undergone aortic valve replacement on initial evaluation. During follow-up (median 36 ± 27 months), 31 aortic valve replacements and 20 cardiac deaths occurred. Multivariate analysis revealed that an AVAI <0.6 cm²/m² (hazard ratio 2.6, 95% confidence interval 1.1 to 6.3; p = 0.03) and peak aortic jet velocity (Vp) >4.0 m/s (hazard ratio 2.6, 95% confidence interval 1.2 to 5.8; p = 0.02) were associated with cardiac events but that an AVA <0.75 cm² was not. The event-free survival of patients with an AVAI of ≥0.6 cm²/m² was better than that for those with an AVAI <0.6 cm²/m² (86% vs 41% at 3 years, p <0.01). Furthermore, patients with an AVAI of ≥0.6 cm²/m² and Vp of ≤4.0 m/s showed an excellent prognosis, but those without these findings had poorer outcomes. In conclusion, AVAI is a powerful predictor of adverse events in asymptomatic patients with severe aortic stenosis. Furthermore, the combination of AVAI and Vp provides additional prognostic information. Watchful observations are required for timely aortic valve replacement in patients with an AVAI of <0.6 cm²/m² or a Vp >4.0 m/s.

Section snippets

Methods

From 2001 to 2007, asymptomatic patients who underwent transthoracic echocardiography and had severe AS, defined as an AVA of <1.0 cm², were retrospectively identified for the present study if they had not undergone aortic valve replacement on initial evaluation. The exclusion criteria were a history of coronary artery disease (diagnosed by clinical, electrocardiographic, echocardiographic, and coronary angiographic evaluation), more than mild mitral valve regurgitation or stenosis, more than

Results

The mean duration of follow-up was 36 ± 27 months. Of the study group, 37 patients had an AVAI of ≥0.6 cm²/m², and 66 patients had an AVAI of <0.6 cm²/m². Compared to patients with AVAI of ≥0.6 cm²/m², those with an AVAI <0.6 cm²/m² did not significantly differ in age, gender, LV ejection fraction, co-morbidities, C-reactive protein, or serum creatinine but exhibited a smaller AVA, higher Vp, greater peak and mean aortic pressure gradient, and larger body surface area. The baseline patient

Discussion

This is the first study to assess the outcomes on the basis of an AVAI. The present study demonstrated that an AVAI of ≥0.6 cm²/m² was frequently observed in patients with an AVA <1.0 cm². Patients with an AVAI of ≥0.6 cm²/m² had better outcomes than those with an AVAI <0.6 cm²/m². Multivariate analysis showed that an AVAI <0.6 cm²/m² and Vp >4.0 m/s were significant predictors of adverse cardiac events, but an AVA <0.75 cm² was not. Patients with an AVAI <0.6 cm²/m² or peak velocity >4.0 m/s

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Cited by (43)

Bedside Physical Examination for the Diagnosis of Aortic Stenosis: A Systematic Review and Meta-analysis
2023, CJC Open
Patients with obstruction to the left ventricular outflow tract from degenerative aortic stenosis (AS) usually do not become symptomatic until their disease becomes graded as severe. We sought to assess the accuracy of the physical examination for the diagnosis of AS of at least moderate severity.
A systematic review and meta-analysis of case series and cohorts of patients who received a cardiovascular physical examination prior to receiving a left heart catheterization or an echocardiogram. PubMed, Ovid MEDLINE, the Cochrane Library, ClinicalTrials.gov, and Embase were searched with a date range from inception through December 10, 2021, without language restrictions.
Our systematic review yielded 7 observational studies with adequate data to perform a meta-analysis on 3 physical examination assessments. Auscultating a diminished second heart sound (likelihood ratio [LR] = 10.87, 95% confidence interval [CI], 3.94-30.12, P < 0.05) and palpating a delayed carotid upstroke (LR = 9.04, 95% CI, 3.12-25.44, P < 0.05) are useful for detecting AS of at least moderate severity. The absence of a systolic murmur radiating to the neck (LR = 0.11, 95% CI, 0.06-0.23, P < 0.05) rules against AS of at least moderate severity.
Low-quality evidence from observational studies supports a diminished second heart sound and a delayed carotid upstroke as having moderate accuracy in diagnosing the presence of AS of at least moderate severity, whereas the absence of a murmur radiating to the neck is equally accurate in excluding this diagnosis.
Les patients présentant une obstruction de la voie d’éjection ventriculaire gauche consécutive à une sténose aortique (SA) dégénérative ne montrent habituellement pas de symptômes avant que la maladie ne soit de grade sévère. Nous cherchions donc à évaluer la fiabilité des examens physiques dans le diagnostic de SA modérée ou plus grave.
Une revue systématique et une métanalyse de séries de cas et de cohortes de patients qui ont subi un examen cardiovasculaire avant de recevoir un cathétérisme du côté gauche du cœur ou un échocardiogramme ont été effectuées. Les bases de données PubMed, Ovid MEDLINE, Cochrane, ClinicalTrials.gov et Embase ont été interrogées pour trouver les études publiées entre la date de début de l’indexation des bases jusqu’au 10 décembre 2021, sans restriction quant à la langue de publication.
Notre revue systématique a permis de relever sept études observationnelles contenant des données permettant de réaliser une métanalyse sur trois examens physiques. La présence d’un deuxième bruit diminué à l’auscultation (quotient de vraisemblance [QV] : 10,87; intervalle de confiance [IC] à 95 % : 3,94 à 30,12; p < 0,05) et d'un flux carotidien démodulé à la palpation (QV : 9,04; IC à 95 % : 3,12 à 25,44; p < 0,05) permet de détecter une SA modérée ou plus grave. L’absence d’un souffle systolique irradiant jusqu’au cou (QV : 0,11; IC à 95 % : 0,06 à 0,23; p < 0,05) permet d’éliminer la possibilité de SA modérée ou plus grave.
Les données de faible qualité provenant d’études observationnelles témoignent d’une fiabilité modérée d’un deuxième bruit diminué et d’un flux carotidien démodulé dans le diagnostic de SA modérée ou plus grave, alors que l’absence d’un souffle irradiant jusqu’au cou présente la même fiabilité dans l’exclusion de ce diagnostic.
Integrating hemodynamics with ventricular and valvular remodeling in aortic stenosis. A paradigm shift in therapeutic decision making
2022, American Heart Journal
Aortic valve stenosis (AS) has traditionally been approached in hemodynamic terms. Although hemodynamics and symptoms have formed the basis of recommending interventional treatment in AS, other factors reflecting left ventricular and valvular and/or vascular remodeling are equally important for the prognosis and outcome of patients with AS. Left ventricular and valvular/vascular remodeling in AS do not consistently correlate with hemodynamic severity of AS. Those remodeling changes are reflected and can be detected by a variety of novel laboratory and imaging techniques, including biomarkers, echocardiography, cardiac magnetic resonance and gated Computer Tomography (CT) imaging. Taking all those elements into Heart Team therapeutic decision making in patients with AS, can significantly improve appropriate patient selection for interventional treatment and patient outcomes. We review this novel approach and propose a simple algorithm for decision making by the Heart Team, in patients with moderate or severe AS.
Asymptomatic severe aortic stenosis, bicuspid aortic valves and moderate aortic stenosis in heart failure: New indications for transcatheter aortic valve implantation
2021, Trends in Cardiovascular Medicine
Aortic stenosis (AS) remains one of the most common valvular heart diseases, with enormous impact on patient survival. Over the past years, transcatheter aortic valve implantation (TAVI) has become a reality worldwide, offering a less invasive method to treat AS. Apart from the classical indications for aortic valve disease, recent studies tried to address unanswered questions for TAVI – asymptomatic severe AS, bicuspid aortic valves and moderate AS in patients with heart failure. This review discusses the rationale of those possible indications, pitfalls and current evidence in the medical literature.
2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
2021, Journal of Thoracic and Cardiovascular Surgery
Simple echocardiographic scoring in screening aortic stenosis with focused cardiac ultrasonography in the emergency department
2021, Journal of Cardiology
Citation Excerpt :
The main results of the present study were: 1) the observation of a strong correlation between the visual AS score for POC-echo performed by emergency physicians and the AVAI for STD-echo performed by expert sonographers; 2) a visual AS score ≥3 for POC-echo performed by emergency physicians had an excellent diagnostic accuracy for moderate or severe AS; and 3) the prevalence of new-onset AS-related events during hospitalization was higher in patients with visual AS score ≥3, as assessed by POC-echo in the emergency department, than in those with visual AS score <3. AS is a progressive and life-threatening disease that carries the risk of severe congestive heart failure, cardiogenic shock, or sudden cardiac death in a symptomatic or even in an asymptomatic stage [10,19–21]. Degenerative AS is one of the most common valvular diseases, especially in elderly populations.
No established methodology exists for diagnosis of aortic stenosis (AS) using focused cardiac ultrasound (FOCUS). We evaluated the diagnostic accuracy of our developed visual AS score for screening AS in an emergency department.
Seventy-two emergency outpatients with suspected cardiovascular disease were studied. Emergency physicians assessed the visual AS score in addition to conducting the standard FOCUS, and then the aortic valve area index (AVAI) was measured by expert sonographers in the echocardiography laboratory. AVAI values >0.85 cm²/m², 0.6–0.85 cm²/m², and <0.6 cm²/m² were defined as no or mild AS, moderate AS, and severe AS, respectively.
Seventeen (24%) patients had moderate or severe AS. Visual AS scores assessed by emergency physicians and by expert sonographers showed excellent agreement (κ = 0.93), and a strong association was noted between the visual AS score assessed by emergency physicians and the AVAI assessed by expert sonographers (R = –0.71, p < 0.0001). A visual AS score ≥3 assessed by emergency physicians had a sensitivity of 82%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 95% for diagnosing moderate or severe AS. The prevalence of new-onset AS-related events during hospitalization was higher in patients with visual AS score ≥3 assessed by emergency physicians than in the remaining patients [7 (50%) vs. 2 (3%), p < 0.0001].
The visual AS score is a useful AS screening tool for emergency physicians who are not expert cardiologists.
2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
2021, Journal of the American College of Cardiology

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Valvular heart diseasePrognostic Value of Aortic Valve Area Index in Asymptomatic Patients With Severe Aortic Stenosis

Section snippets

Methods

Results

Discussion

Am J Cardiol

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Should early elective surgery be performed in patients with severe but asymptomatic aortic stenosis?

Eur Heart J

Natural history of very severe aortic stenosis

Circulation

Outcome of 622 adults with asymptomatic, hemodynamically significant aortic stenosis during prolonged follow-up

Circulation

Low-gradient “severe” aortic stenosis with normal systolic function: time to refine the guidelines?

Circulation

Valvular heart disease
Prognostic Value of Aortic Valve Area Index in Asymptomatic Patients With Severe Aortic Stenosis