Mid-term prognostic value of the novel staging of cardiac damage in asymptomatic patients with moderate to severe aortic stenosis
Authors: Gil Fernandez J , Candela Ferre J , Rojas Lavado G , Gonzalez-Bartol E , Aristizabal-Duque C , Gomez-Salvador I , Sevilla Ruiz T , San Roman JA 
Published: February 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Recently, a new staging of patients with  moderate to severe aortic stenosis (AS) based on extra-aortic valve cardiac damage has been described to stratify the prognostic of both, asymptomatic and symptomatic patients.

Purpose

 To test the mid-term prognostic value of this staging system in patients with asymptomatic moderate to severe AS.

Methods

We analyzed a retrospective cohort of 96 patients with at least moderate AS who were systematically studied with echocardiography and cardiac magnetic resonance imaging. Patients were classified according to the staging classification of extra-aortic valve damage: no cardiac damage associated with the valve stenosis (Stage 0), left ventricular (LV) damage: LV mass index &gt;95 g/m2 in women and &gt;115 g/m2 in men and or E/E´ratio &gt;14 and/or LV ejection fraction &lt;50% (Stage 1), mitral valve or left atrial (LA) damage: LA volume &gt;34 ml/m2, and/or atrial fibrillation and/or ≥ moderate mitral regurgitation (Stage 2), tricuspid valve or pulmonary vasculature damage: systolic pulmonary arterial pressure ≥60 mm Hg and/or the presence of moderate or greater tricuspid regurgitation (Stage 3), or right ventricular damage:  tricuspid annulus systolic velocity S´&lt; 9.5 cm/s, TAPSE &lt; 17 mm, and/or RV ejection fraction &lt; 50% (Stage 4). Given the small number of patients in Stages 3 and 4, patients were merged together in a single group. The primary endpoint was all-cause mortality during a follow-up of 5 years, regardless of whether the patient underwent aortic valve replacement. Kaplan-Meier curves and log-rank test of the time-to-death data were used.

Results

At baseline patients had a mean age of 70.9 years old and 71.9% were male. Most of patients had hypertension (70.8%) and dyslipidemia (55.2%). 20.8% had diabetes mellitus and only 10.4% had previous coronary artery disease. The mean transvalvular gradient was 39 ± 14 mmHg and the mean aortic valve area was 1.04 ± 0.24 cm2. According to the staging scheme, 37  patients were classified in Stage 0 (38.5%), 32 in Stage 1 (33.3%), 23 in Stage 2 (24%) and 4 in the group of Stage 3-4 (4.2%). During 5 years of follow-up, 44 patients developed symptoms (33 dyspnea, 18 angina and 5 syncope), up to 40% of patients underwent aortic valve replacement and 20 patients died (20.8%), 7 of them due to cardiovascular causes. At 5 years, there was a significant decrease in cumulative survival rates according to staging and group 2 presented the worst prognosis in our series: 95.7% in Stage 0, 81.1% in Stage 1, 75% in Stages 3-4 and 65% in Stage 2 (p = 0.04).

Conclusions

The novel staging scheme based in imaging evaluation of the extra-aortic [T1] cardiac damage provides mid-term prognostic information in patients with moderate to severe AS. Patients without extravalvular damage present an excellent 5-year survival, mortality increases significatively when the damage extends beyond the LV. Abstract Figure. Baseline Characteristics  Abstract Figure. Survival Analysis