Author + information
- Received February 12, 2019
- Revision received April 11, 2019
- Accepted April 12, 2019
- Published online July 22, 2019.
- Lionel Tastet, MSa,
- Christophe Tribouilloy, MDb,
- Sylvestre Maréchaux, MDc,
- E. Mara Vollema, MDd,
- Victoria Delgado, MDd,
- Erwan Salaun, MDa,
- Mylène Shen, MSa,
- Romain Capoulade, PhDe,
- Marie-Annick Clavel, DVM, PhDa,
- Marie Arsenault, MDa,
- Élisabeth Bédard, MDa,
- Mathieu Bernier, MDa,
- Jonathan Beaudoin, MDa,
- Jagat Narula, MDf,
- Patrizio Lancellotti, MDg,
- Jeroen J. Bax, MDd,
- Philippe Généreux, MDh,i,j and
- Philippe Pibarot, DVM, PhDa,∗ (, )@PPibarot
- aQuébec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
- bDepartment of Cardiology, Amiens University Hospital Center, Amiens, France
- cDepartment of Cardiology, GCS-Hospital Group of the Catholic Institute of Lille, Catholic University of Lille, Lille, France
- dDepartment of Cardiology, Heart and Lung Center, Leiden University Medical Center, Leiden, the Netherlands
- eThoracic Institute, French National Institute of Health and Medical Research (INSERM), French National Center for Scientific Research (CNRS), University Hospital Center of Nantes, University of Nantes, Nantes, France
- fDepartment of Cardiology, Mount Sinai Hospital, New York, New York
- gDepartment of Cardiology, GIGA Cardiovascular Sciences, Cardio-Oncology Clinic, University of Liège Hospital, Sart Tilman University Hospital Center, Liège, Belgium
- hGagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey
- iClinical Trials Center, Cardiovascular Research Foundation, New York, New York
- jDepartment of Cardiology, Sacré-Coeur Hospital of Montréal, Montréal, Québec, Canada
- ↵∗Address for correspondence:
Dr. Philippe Pibarot, Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 Chemin Sainte-Foy, Québec City, Québec G1V 4G5, Canada.
Background The optimal timing of intervention in patients with asymptomatic severe aortic stenosis (AS) remains controversial.
Objectives This multicenter study sought to test and validate the prognostic value of the staging of cardiac damage in patients with asymptomatic moderate to severe AS.
Methods This study retrospectively analyzed the clinical, Doppler echocardiographic, and outcome data that were prospectively collected in 735 asymptomatic patients (71 ± 14 years of age; 60% men) with at least moderate AS (aortic valve area <1.5 cm2) and preserved left ventricular ejection fraction (≥50%) followed in the heart valve clinics of 4 high-volume centers. Patients were classified according to the following staging classification: no cardiac damage associated with the valve stenosis (Stage 0), left ventricular damage (Stage 1), left atrial or mitral valve damage (Stage 2), pulmonary vasculature or tricuspid valve damage (Stage 3), or right ventricular damage or subclinical heart failure (Stage 4). The primary endpoint was all-cause mortality.
Results At baseline, 89 (12%) patients were classified in Stage 0, 200 (27%) in Stage 1, 341 (46%) in Stage 2, and 105 (14%) in Stage 3 or 4. Median follow-up was 2.6 years (interquartile range: 1.1 to 5.2 years). There was a stepwise increase in mortality rates according to staging: 13% in Stage 0, 25% in Stage 1, 44% in Stage 2, and 58% in Stages 3 to 4 (p < 0.0001). The staging was significantly associated with excess mortality in multivariable analysis adjusted for aortic valve replacement as a time-dependent variable (hazard ratio: 1.31 per each increase in stage; 95% CI: 1.06 to 1.61; p = 0.01), and showed incremental value to several clinical variables (net reclassification index = 0.34; p = 0.003).
Conclusions The new staging system characterizing the extra-aortic valve cardiac damage provides incremental prognostic value in patients with asymptomatic moderate to severe AS. This staging classification may be helpful to identify asymptomatic AS patients who may benefit from elective aortic valve replacement.
This work was supported by grants FDN-143225 and MOP-114997 from the Canadian Institutes of Health Research (CIHR) and a grant from the Foundation of the Québec Heart and Lung Institute (QHLI). Mr. Tastet is supported by a doctoral scholarship from Fonds de Recherche en Santé-Québec (FRSQ). Dr. Vollema has received unrestricted institutional research grants from Medtronic, Biotronik, Boston Scientific, Edwards Lifesciences, and GE Healthcare. Dr. Delgado is the recipient of the Sir Jules Thorn Award for Biomedical Research 2015 (15/JTA); has received unrestricted institutional research grants from Medtronic, Biotronik, Boston Scientific, Edwards Lifesciences, and GE Healthcare; and has received speaker’s fees from Abbott Vascular. Ms. Shen is supported by a doctoral scholarship from FRSQ. Dr. Capoulade is supported by a post-doctoral fellowship grant from the Institut de France - Fondation Lefoulon-Delalande; and holds a “Connect Talent” research chair from Region Pays de la Loire and Nantes Metropole (France). Dr. Clavel holds a young investigator grant from the QHLI. Dr. Arsenault is a research scholar from Fonds de Recherche en Santé - Québec (FRSQ). Dr. Bax has received unrestricted institutional research grants from Medtronic, Biotronik, Boston Scientific, Edwards Lifesciences, and GE Healthcare; and has received speaker fees from Abbott Vascular. Dr. Généreux has received speaker fees from Edwards Lifesciences, Medtronic, Tryton Medical, Cardinal Health, Abbott Vascular, and Cardiovascular Systems; has received consulting fees from Boston Scientific, Cardiovascular Systems, Edwards Lifesciences, and Pi-Cardia; has received an institutional research grant from Boston Scientific; has been a proctor for Edwards Lifesciences; has served on the Advisory Boards of Boston Scientific and Cardinal Health; is a principal investigator on the EARLY TAVR trial; and has equity in SIG.NUM, SoundBite Medical Solutions, Saranas, and Pi-Cardia. Dr. Pibarot holds the Canada Research Chair in Valvular Heart Diseases from CIHR; and has received funding from Edwards Lifesciences and Medtronic for echocardiography core laboratory analyses in the field of transcatheter aortic valve replacement with no direct personal compensation. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Roberto M. Lang, MD, served as Guest Associate Editor for this paper.
Listen to this manuscript's audio summary by Editor-in-Chief Dr. Valentin Fuster on JACC.org.
- Received February 12, 2019.
- Revision received April 11, 2019.
- Accepted April 12, 2019.
- 2019 American College of Cardiology Foundation
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