Olaf Schulz1,2, Debora Brala2,3, Thomas G. Allison4, Ingolf Schimke2
1Praxis für interventionelle und konventionelle Kardiologie Spandau, Kardio-West, Berlin, 2Universitätsmedizin Berlin, Charite, Humboldt Universität Berlin, 3Sana Klinikum Lichtenberg, Berlin, Germany, 4Mayo Clinic and Medical School, Rochester, MN, USA
Background and aim of the study: Managing patients with asymptomatic severe aortic stenosis (AS) remains a major challenge. Myocardial as well as cardiocirculatory reserve have been hypothesized to predict outcome in patients with asymptomatic AS.
Methods: A total of 48 patients (indexed aortic valve area 0.39 ± 0.12 cm2/m2; ejection fraction (EF) 67 ± 7%) underwent spiroergometry and dobutamine stress echocardiography. Death or valve surgery served as a combined endpoint for follow up.
Results: Thirty-seven patients reached the endpoint after a mean of 756 days (range: 100-2146 days). Age- and gender-corrected univariate Cox proportional analysis revealed the presence of mild obstructive lung disease, stroke work loss (SWL), end-systolic diameter index, and E/Flow propagation velocity as the best predictive clinical, valvular, cardiostructural, and left ventricular filling pressure parameters, respectively. After inclusion of these parameters into a baseline multivariable Cox proportional
hazard model, SWL (HR 1.21 per rise of 1 unit, CI 1.08-1.35, p = 0.0005) and female gender (HR 3.37, CI 1.50-7.59, p = 0.0044) were independently predictive. Similarly, the best-performing myocardial parameter, EF after dobutamine, was independently predictive (HR 0.75 per 5 units, CI 0.57-0.99, p = 0.035) after inclusion. The best-performing exercise capacity parameter, Wattmax, was of borderline significance (HR 0.93 per 5 units, CI 0.86-1.00, p = 0.0505). For each parameter, cut-off values were determined by time-dependent receiver-operator characteristics. The Kaplan-Meier curves of the patients above versus below the cut-offs differed significantly for SWL (p = 0.001), Wattmax (p = 0.001), and gender (p = 0.013).
Conclusion: Besides SWL and female gender, the EF after dobutamine as well as highest exercise stress intensity reached are helpful in determining the prognosis of asymptomatic patients with moderate-severe AS.
The Journal of Heart Valve Disease 2015;24:457-464
|Myocardial and Cardiocirculatory Reserve in Asymptomatic Aortic Stenosis and Preserved Ejection Fraction|
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