pronostico de estenosis aortica de bajo flujo articulo
DESCRIPTION
articulo sobre el pronostico de las valvulopatis de bajo flujo, en concreto de las estenosis aorticasTRANSCRIPT
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DOI: 10.1161/CIRCULATIONAHA.112.001290
Predictors of Mortality and Outcomes of Therapy in Low Flow Severe Aortic
Stenosis: A PARTNER Trial Analysis
Running title:Herrmann et al.; Predictors of Outcomes in Low Flow Severe Aortic Stenosis
Howard C. Herrmann, MD1; Philippe Pibarot, PhD
2; Irene Hueter, PhD
3; Zachary M. Gertz, MD
4;
William J. Stewart, MD5; Samir Kapadia, MD
5; E. Murat Tuzcu, MD
5; Vasilis Babaliaros, MD
6;
Vinod Thourani, MD6; Wilson Y. Szeto, MD
1; Joseph E. Bavaria, MD
1; Susheel Kodali, MD
3;
Rebecca T. Hahn, MD
3
; Mathew Williams, MD
3
; D. Craig Miller, MD
7
; Pamela S. Douglas, MD
8
;Martin B. Leon, MD
3
1University of Pennsylvania, Philadelphia, PA;
2Quebec Heart and Lung Institute, Laval
University, Quebec, Canada;3Cardiovascular Research Foundation and Columbia University,
New York, NY;4VCU School of Medicine, Richmond, VA;
5Cleveland Clinic, Cleveland, OH;
6Emory University, Atlanta, GA;
7Stanford University, Palo Alto, California;
8Duke University,
Durham, NC
ebecca T. Hahn, MD ; Mathew Williams, MD ; D. Craig Miller, MD ; Pamela S. , D
Martin B. Leon, MD3
1
ity o ennsylvania, Philadelphia, ;
Quebec Heart a ung Institute, Laval
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5
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c, la H;E ory Univer i y, tlant , A;
t n ord ni e sit oAl o Calif r
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DOI: 10.1161/CIRCULATIONAHA.112.001290
Abstract:
BackgroundThe prognosis and treatment of patients with low flow (LF) severe aortic stenosis
(AS) is controversial.
Methods and ResultsThe PARTNER trial randomized patients with severe AS to medical
management (MM) vs transcatheter (TAVR) aortic valve replacement ("inoperable" cohort) and
surgery (SAVR) vs TAVR (high risk cohort). Among 971 patients with evaluable
echocardiograms (92%), LF (stroke volume index (SVI) 35 ml/m2) was observed in 530 (55%),
LF and low ejection fraction (
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DOI: 10.1161/CIRCULATIONAHA.112.001290
Aortic valve replacement (AVR) is indicated for patients with severe aortic stenosis (AS)
associated with either symptoms or left ventricular (LV) dysfunction1, 2
. Severe AS is generally
defined as an aortic valve area < 1.0 cm2 and a mean transvalvular gradient of > 40 mmHg.
However, many patients with symptomatic and severe AS may have lower gradients due to left
ventricular systolic dysfunction (so called low flow, low ejection fraction), high afterload and
pronounced LV concentric remodeling (paradoxical low flow, normal ejection fraction), and
due to errors or assumptions inherent in the measurement of gradient and valve area3-7
. These
patients have a similar or worse prognosis than those with classic AS, both with and without
surgery6-14
. However, little is known about the prognostic value of low flow independent of
gradient and ejection fraction, and its treatment.
Transcatheter aortic valve replacement (TAVR) has recently emerged as an alternative to
open surgical AVR (SAVR) in both inoperable and high-risk patients with severe AS15-18
. In
order to better understand the implications of low flow in severe aortic stenosis, we utilized core
echocardiographic laboratory data to examine the prognostic implications of low flow (LF), low
radient and ejection fraction, and its treatment.
Transcatheter aortic valve replacement (TAVR) has recently emerged as an alternative to
pe A (SAVR) in both inoperabl
e high-risk pat nt h severe AS15-18
. In
rd r to better
u er m i
ns f ow fl
o i s
e a
orticste
n
i , e u li c re
o i p icla o
a or
o
e p o
n c l s l w w( l
w
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DOI: 10.1161/CIRCULATIONAHA.112.001290
severe AS. Inclusion criteria for this trial included a site-measured echocardiographic aortic
valve area of < 0.8 cm2 (or indexed AVA 40 mmHg or a peak aortic-jet velocity > 4.0 m/s (64 mmHg). Important exclusion
criteria included substantial coronary artery disease requiring revascularization, EF < 20%, or
severe (4+) aortic (AR) or mitral regurgitation (MR). Patients were treated with the Edwards
SAPIEN balloon-expandable bovine pericardial heart valve system (Edwards Lifesciences). The
primary end point for the study (both cohorts) was all-cause mortality at 1 year or more, but
follow-up has continued allowing for subsequent analyses with adjudicated events17, 18
. All
echocardiograms were analyzed in an independent core laboratory19
. The database for the study
is maintained at the Cardiovascular Research Foundation (New York, NY), where independent
statistical analyses can be requested by investigators.
In this analysis, patients with evaluable echocardiograms were classified into 2 groups
based on baseline echocardiographic stroke volume index of < 35 ml/m2 (low flow, LF) or
normal flow (NF)2, 4
. The LF group was then further divided based on EF < 50% (LF LEF) or
s maintained at the Cardiovascular Research
Foundation (New York, NY), whe
re i
d t
tatistical analyses can be requested by investigators.
a sis, patients with evaluable h cardiograms er ssified into 2 groups
as d on baseli e
ec c
r ra
i tr kev lu in