Staging Cardiac Damage in Patients With Asymptomatic Aortic Valve Stenosis

Lionel Tastet (1) , Christophe Tribouilloy (2) , Sylvestre Maréchaux (3) , E. Mara Vollema (4) , Victoria Delgado (4) , Erwan Salaun (1) , Mylene Shen (1) , Romain Capoulade (5, 6) , Marie-Annick Clavel (1) , Marie Arsenault (1) , Elisabeth Bedard (1) , Mathieu Bernier (1) , Jonathan Beaudoin (1) , Jagat Narula (7) , Patrizio Lancellotti (8) , Jeroen J. Bax (4) , Philippe Genereux (9) , Philippe Pibarot (1)

1 ULaval - Université Laval [Québec]
2 CHU Amiens-Picardie
3 GHICL - Groupe Hospitalier de l'Institut Catholique de Lille
4 LUMC - Leiden University Medical Center
5 ITX - ITX - unité de recherche de l'institut du thorax
6 CHU Nantes - Centre Hospitalier Universitaire de Nantes
7 MSSM - Icahn School of Medicine at Mount Sinai [New York]
8 GIGA-Research - Groupe Interdisciplinaire de Génoprotéomique Appliquée
9 Hôpital du Sacré-Coeur de Montréal

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 cm(2)) 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. (C) 2019 by the American College of Cardiology Foundation.

Mots clés: aortic valve replacement; aortic valve stenosis; asymptomatic; disease staging; echocardiography

Domaines: Sciences du Vivant [q-bio]

Lionel Tastet, Christophe Tribouilloy, Sylvestre Maréchaux, E. Mara Vollema, Victoria Delgado, et al.. Staging Cardiac Damage in Patients With Asymptomatic Aortic Valve Stenosis. Journal of the American College of Cardiology, 2019, 74 (4), pp.550-563. ⟨10.1016/j.jacc.2019.04.065⟩. ⟨hal-03580000⟩