Staging classification of aortic stenosis based on the extent of cardiac damage

Philippe Généreux, Philippe Pibarot, Björn Redfors, Michael J Mack, Raj R Makkar, Wael A Jaber, Lars G Svensson, Samir Kapadia, E Murat Tuzcu, Vinod H Thourani, Vasilis Babaliaros, Howard C Herrmann, Wilson Y Szeto, David J Cohen, Brian R Lindman, Thomas McAndrew, Maria C Alu, Pamela S Douglas, Rebecca T Hahn, Susheel K Kodali, Craig R Smith, D Craig Miller, John G Webb, Martin B Leon, Philippe Généreux, Philippe Pibarot, Björn Redfors, Michael J Mack, Raj R Makkar, Wael A Jaber, Lars G Svensson, Samir Kapadia, E Murat Tuzcu, Vinod H Thourani, Vasilis Babaliaros, Howard C Herrmann, Wilson Y Szeto, David J Cohen, Brian R Lindman, Thomas McAndrew, Maria C Alu, Pamela S Douglas, Rebecca T Hahn, Susheel K Kodali, Craig R Smith, D Craig Miller, John G Webb, Martin B Leon

Abstract

Aims: In patients with aortic stenosis (AS), risk stratification for aortic valve replacement (AVR) relies mainly on valve-related factors, symptoms and co-morbidities. We sought to evaluate the prognostic impact of a newly-defined staging classification characterizing the extent of extravalvular (extra-aortic valve) cardiac damage among patients with severe AS undergoing AVR.

Methods and results: Patients with severe AS from the PARTNER 2 trials were pooled and classified according to the presence or absence of cardiac damage as detected by echocardiography prior to AVR: no extravalvular cardiac damage (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 (Stage 4). One-year outcomes were compared using Kaplan-Meier techniques and multivariable Cox proportional hazards models were used to identify 1-year predictors of mortality. In 1661 patients with sufficient echocardiographic data to allow staging, 47 (2.8%) patients were classified as Stage 0, 212 (12.8%) as Stage 1, 844 (50.8%) as Stage 2, 413 (24.9%) as Stage 3, and 145 (8.7%) as Stage 4. One-year mortality was 4.4% in Stage 0, 9.2% in Stage 1, 14.4% in Stage 2, 21.3% in Stage 3, and 24.5% in Stage 4 (Ptrend < 0.0001). The extent of cardiac damage was independently associated with increased mortality after AVR (HR 1.46 per each increment in stage, 95% confidence interval 1.27-1.67, P < 0.0001).

Conclusion: This newly described staging classification objectively characterizes the extent of cardiac damage associated with AS and has important prognostic implications for clinical outcomes after AVR.

Keywords: Aortic stenosis; Aortic valve; Aortic valve replacement; Classification; Staging; Transcatheter aortic valve implantation; Transcatheter aortic valve replacement.

© The Author 2017. Published on behalf of the European Society of Cardiology.

Figures

Figure 1
Figure 1
Cardiac stratification of aortic stenosis based on the extent of cardiac damage. LA, left atrial; LV, left ventricular; RV, right ventricular.
Figure 2
Figure 2
One-year outcomes after aortic valve replacement according to the extension of cardiac damage. (A) One-year all-cause death; (B) 1-year cardiac death; (C) all-cause death with 30-day landmark analysis (D) cardiac death with 30-day landmark analysis.
Figure 3
Figure 3
Combination of the newly proposed cardiac damage staging classification and the valvular grading severity classification for patients presenting with aortic stenosis. Green represent a potential Class I aortic valve replacement (AVR) indication, yellow represents a potential Class IIa or IIb AVR indication, and red indicates a potential Class III AVR indication. AVA, aortic valve area; AVAi, aortic valve area index; LA, left atrial; MG, mean gradient; PA, pulmonary artery; RV, right ventricular.

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