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Contractile reserve: a key factor in aortic stenosis
Session:
Comunicações Orais (Sessão 3) - Doença valvular
Speaker:
Miguel Azaredo Raposo
Congress:
CPC 2022
Topic:
F. Valvular, Myocardial, Pericardial, Pulmonary, Congenital Heart Disease
Theme:
15. Valvular Heart Disease
Subtheme:
15.2 Valvular Heart Disease – Epidemiology, Prognosis, Outcome
Session Type:
Comunicações Orais
FP Number:
---
Authors:
Miguel Azaredo Raposo; Pedro Silvério António; Joana Rigueira; Sara Couto Pereira; Beatriz Valente Silva; Pedro Alves da Silva; Ana Beatriz Garcia; Ana Margarida Martins; Catarina Simões de Oliveira; Catarina Gregório; Ana Abrantes; Susana Gonçalves; Daniel Caldeira; Cláudio David; Fausto j. Pinto; Ana g. Almeida
Abstract
<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000"><strong>Introduction: </strong></span></span></span><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000">Stress echocardiography(SE) is essential in the workup of patients(pts) with aortic stenosis(AS) with reduced left ventricular ejection fraction and low systolic volume. Our aim was to determine the prognostic impact of contractile reserve (CR) in low-flow low-gradient (LFLG) AS.</span></span></span></p> <p> </p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000"><strong>Methods: </strong></span></span></span><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000">Retrospective, single-center study of consecutive pts with LFLG AS (mean transvalvular gradient <40 mmHg, LVEF < 50%, indexed stroke volume (SVi) <=35 mL/m</span></span></span><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000"><sup>2</sup></span></span></span><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000"> and an aortic valve area (AVA) <=1 cm</span></span></span><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000"><sup>2</sup></span></span></span><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000">) submitted to SE between 01/2014 and 06/2021. Epidemiological, clinical and echocardiographic data were recorded. Patients were stratified by the presence of CR, defined as ≥20% increase in SVi during SE. Primary endpoint was defined as time to first major event (composite endpoint of all-cause mortality and heart failure (HF) hospitalization). Predictors of major events were analyzed by T-student test and Cox regression.</span></span></span></p> <p> </p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000"><strong>Results: </strong></span></span></span><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000">Fifty-seven pts were included, (40 male, 75.6±8.5 years of age). Regarding cardiovascular risk factors, 48 pts had hypertension, 42 dyslipidemia, 28 diabetes and 28 coronary artery disease (CAD). At baseline, 34 pts were in NYHA functional class II and 20 pts in NYHA III. </span></span></span></p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000">The mean follow-up (FUP) period was 22.6±24.6 months. Exercise SE was performed in 2 pts and dobutamine SE in 55 pts. At rest,</span></span></span><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#ff0000"> </span></span></span><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000">the mean LVEF was 34±10.7%, SVi 32±8.7 ml/m2, median transvalvular gradient 25.5±9 mmHg, AVAi 0.48±0.14 cm/m</span></span></span><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000"><sup>2</sup></span></span></span><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000">. During stress the mean SVi was 38±10.9 ml/m2, median transvalvular gradient 34±13 mmHg, AVAi 0.54±0.17 cm/m</span></span></span><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000"><sup>2</sup></span></span></span><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000">. CR was present in 39 pts. During SE, 28 pts had true severe AS, 11 pts moderate AS, 5 pseudo-severe AS and the remaining were inconclusive. Twenty-six pts underwent valve implantation(VI), most of which percutaneous aortic VI. </span></span></span></p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000">The absence of CR revealed to be a predictor of worst prognosis, with more major events in FUP (LogRank 5.237, p = 0.022), especially in pts who were not submitted to VI.</span></span></span></p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000">At univariate analysis, NYHA class (p=0.009) and the absence of CR (p=0.016) were the only predictors for the primary endpoint. The absence of CR was the sole independent predictor at multivariate analysis (HR 0.349; 95%CI 0.176-0.692, p=0.003). </span></span></span></p> <p><br /> <span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000"><strong>Conclusions: </strong></span></span></span><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000">NYHA functional class and CR were predictors of major events in pts with LFLG AS. The absence of CR was the only independent predictor at multivariate analysis. This study shows the importance of clinical and SE assessment of CR for prediction of major events in these pts. </span></span></span></p>
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