Cardiac Damage: Should we start to assess it?

Courtesy of Dr. Carlos Fava.

The current recommendation for  aortic valve replacement is based on stenosis severity based on valvular criteria (mean transvalvular gradient, peak aortic velocity and valve index area) and the presence of symptoms, in addition to comorbidities, mainly for risk stratification. However, ventricular damage and/or its effect on cardiovascular hemodynamics are not regarded as significant.

The PARTNER 2 findings were staged according to echocardiography. They were divided into 5 stages:

• Stage 0: no damage.
• Stage 1: left ventricular damage due to ventricular hypertrophy (LVMI >115 men, >95g/m², women g/m², E/e >14, FEY <50%).
• Stage 2: left atrium or mitral valve damage (index volume LA >34 ml/m², moderate/severe mitral regurgitation, or presence of atrial failure).
• Stage 3: pulmonary vasculature or tricuspid damage (systolic pulmonary atrial pressure ≥60 mmHg or moderate/severe tricuspid regurgitation).
• Stage 4: right ventricular damage (moderate/severe).

Stage 0 was seen in 47 patients (2.8%), stage 1 in 212 (12.8%), stage 2 in 844 (50.4%), stage 3 in 413 (24.9%) and stage 4 in 145 (8.7%).

Read also: “Bleeding and Mortality in Transcatheter Aortic Valve Replacement”.

Those with more advanced stages were older, had higher BMI and higher STS and EuroSCORE, more often had diabetes, prior MI, CRM and COPD.

At one year, global and cardiac death were higher, in direct correlation with the extent of cardiac damage (stage 0: 4.4%; stage 1: 9.2%; stage 2: 14.3%; stage 3: 21.3%; and stage 4: 24.5% (p_trend=<0.001).

Read also: “SOLACI CACI 2017 | Role of embolic protection during Transcatheter Aortic valve replacement”.

The extent of cardiac damage was independently associated to higher mortality after AVR and for each stage increment, 1-year mortality risk increased by 45%.

Conclusion

This new staging classification characterizing cardiac damage associated with aortic stenosis has prognostic implications for post TAVR evolution.

Commentary

Even though the current risk assessment criteria and the presence of comorbidities have proved useful to decide on the best course of action, there has always been something “off” when it came to matching clinical criteria and risk stratification.

This new staging system might help shed some light on this matter. Most likely, if we combine it with the risk stratification system in place, we will improve risk scores, in addition to providing prognostic information.

Gentileza del Dr. Carlos Fava.

Original title: Staging classification of aortic stenosis base on the extent of cardiac damage.

Reference: Philippe Généreux, et al. European Society of Cardiology 2017;38:3351-2258.

We are interested in your opinion. Please, leave your comments, thoughts, questions, etc., below. They will be most welcome.