Prognostic Value of Aortic Valve Area by Doppler Echocardiography in Patients With Severe Asymptomatic Aortic Stenosis

International audienceBackground-The aim of this study was to evaluate the relationship between aortic valve area (AVA) obtained by Doppler echocardiography and outcome in patients with severe asymptomatic aortic stenosis and to define a specific threshold of AVA for identifying asymptomatic patients at very high risk based on their clinical outcome. Methods and Results-We included 199 patients with asymptomatic severe aortic stenosis (AVA 0.6 cm(2) (hazard ratio 3.39; 95% CI 1.80-6.40; P<0.0001). Conclusions-Patients with severe asymptomatic aortic stenosis and AVA <= 0.6 cm(2) displayed an important increase in the risk of adverse events during short-term follow-up. Further studies are needed to determine whether elective aortic valve replacement improves outcome in this high-risk subgroup of patients

Impact of low stroke volume on mortality in patients with severe aortic stenosis and preserved left ventricular ejection fraction

International audienceAims In patients with severe aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF), low flow (LF) is currently defined using Doppler-echocardiography by a stroke volume index (SVi) 35 mL/m(2) or SV > 70 mL; (ii) SVi 30-35 mL/m(2) or SV 55-70 mL; and (iii) SVi 35 mL/m(2) [adjusted hazard ratio (HR) 1.60 (1.17-2.18)] and SV 70 mL [adjusted HR 1.84 (1.32-2.58)]. Similar mortality risk was observed for SVi 30-35 mL/m(2) vs. > 35 mL/m(2) [adjusted HR 1.05(0.78-1.41)], and for SV 55-70 mL vs. > 70 mL [adjusted HR 1.22 (0.94-1.58)]. The prognostic impact of SVi < 30 mL/m(2) and SV < 55mL was consistent in subgroups, including asymptomatic patients and patients with low-gradient severe AS. Conclusion Low flow defined as SVi < 30 mL/m(2) or SV < 55mL is an important outcome predictor in severe AS with preserved LVEF under medical and surgical management. Further studies are needed to prospectively test these values for risk stratification and decision making

Impact of Mean Transaortic Pressure Gradient on Long Term Outcome in Patients With Severe Aortic Stenosis and Preserved Left Ventricular Ejection Fraction

International audienceBACKGROUND:Mean transaortic pressure gradient (MTPG) has never been validated as a predictor of mortality in patients with severe aortic stenosis. We sought to determine the value of MTPG to predict mortality in a large prospective cohort of severe aortic stenosis patients with preserved left ventricular ejection fraction and to investigate the cutoff of 60 mm Hg, proposed in American guidelines.METHODS AND RESULTS:A total of 1143 patients with severe aortic stenosis defined by aortic valve area ≤1 cm2 and MTPG ≥40 mm Hg were included. The population was divided into 3 groups according to MTPG: between 40 and 49 mm Hg, between 50 and 59 mm Hg, and ≥60 mm Hg. The end point was all-cause mortality. MTPG was ≥60 mm Hg in 392 patients. Patients with MTPG ≥60 mm Hg had a significantly increase risk of mortality compared with patients with MTPG <60 mm Hg (hazard ratio [HR]=1.62 [1.27-2.05] P<0.001), even for the subgroup of asymptomatic or minimally symptomatic patients (HR=1.56 [1.04-2.34] P=0.032). After adjustment for established outcome predictors, patients with MTPG ≥60 mm Hg had a significantly higher risk of mortality than patients with MTPG <60 mm Hg (HR=1.71 [1.33-2.20] P<0.001), even after adjusting for surgery as a time-dependent variable (HR=1.71 [1.43-2.11] P<0.001). Similar results were observed for the subgroup of asymptomatic or minimally symptomatic patients (HR=1.70 [1.10-2.32] P=0.018 and HR=1.68 [1.20-2.36] P=0.003, respectively).CONCLUSIONS:This study shows the negative prognostic impact of high MTPG (≥60 mm Hg), on long-term outcome of patients with severe aortic stenosis with preserved left ventricular ejection fraction, irrespective of symptoms

Left Atrial Volume and Mortality in Patients With Aortic Stenosis

International audienceBackground-Left atrium (LA) enlargement is common in patients with aortic stenosis (AS), yet its prognostic implications are unclear. This study investigates the value of left atrial volume (LAV) and LAV normalized to body size for predicting mortality in AS. Methods and Results-We included 1351 patients with AS in sinus rhythm at diagnosis and analyzed the occurrence of all-cause death during follow-up with medical and surgical management. Five parameters of LA enlargement were tested: nonindexed LAV and normalized LAV by ratiometric (LAV/body surface area [BSA] and LAV/height) and allometric (LAV/BSA1.7 and LAV/height(2.0)) scaling. For each parameter, patients in the highest quartile were at high risk of death, whereas outcome was better and similar for the other quartiles. Five-year survival was lower for patients with LAV >95 mL and LAV/BSA >50 mL/m(2) compared with those with no or mild LA enlargement (both P95 mL (adjusted hazard ratio, 1.40 [95% confidence interval, 1.06-1.88]) and LAV/BSA >50 mL/m(2) (adjusted hazard ratio, 1.42 [95% confidence interval, 1.08-1.91]). LAV/BSA and LAV showed good and similar predictive performance, whereas other scaling methods did not show better outcome prediction. In patients with severe AS at baseline, preserved (>= 50%) ejection fraction, and no or minimal symptoms, LA enlargement was significantly associated with mortality (adjusted hazard ratio, 1.87 [95% confidence interval, 1.02-3.44] for LAV >95 mL, and adjusted hazard ratio, 1.90 [95% confidence interval, 1.03-3.56] for LAV/BSA >50 mL/m(2)). Conclusions-LA enlargement is an important predictor of mortality in AS, incrementally to known predictors of outcome. LAV and LAV/BSA have comparable predictive performance and should be assessed in clinical practice for risk stratification

A framework for enhancing the replicability of behavioral MIS research using prediction oriented techniques

The ongoing scientific discourse surrounding the replication crisis in behavioral research, including management information systems (MIS) research, underscores the importance of innovative and rigorous approaches to theory development and validation. This article proposes the EP-mixed framework, which addresses the necessity of an ontological distinction between explanation and prediction in MIS theories, along with the epistemological challenges associated with conflating exploratory and confirmatory research during the design of robust, replicable theories. EP-mixed refers to theories that explain and predict (i.e., EP theories) developed using a mixed mode that combines the strengths of both exploratory and confirmatory research. The EP-mixed framework guides researchers in selecting appropriate analytical approaches based on their research goals and the type of theory being developed. While it can be applied in conjunction with a broad spectrum of statistical methods to enhance the robustness and replicability of MIS theories, we elaborate on the predictive analytic tools available in partial least squares structural equation modeling (PLS-SEM) as an exemplar for operationalizing the framework

Relationship Between the Ratio of Acceleration Time/Ejection Time and Mortality in Patients With High-Gradient Severe Aortic Stenosis

International audienceBackground The ratio of acceleration time/ejection time (AT/ET) is a simple and reproducible echocardiographic parameter that integrates aortic stenosis severity and its consequences on the left ventricle. No study has specifically assessed the prognostic impact of AT/ET on outcome in patients with high-gradient severe aortic stenosis (SAS) and no or mild symptoms. We sought to evaluate the relationship between AT/ET and mortality and determine the best predictive AT/ET cutoff value in these patients. Methods and Results A total of 353 patients (median age, 79 years; 46% women) with high-gradient (mean pressure gradient >= 40 mm Hg and/or aortic peak jet velocity >= 4 m/s) SAS, left ventricular ejection fraction >= 50%, and no or mild symptoms were studied. The impact of AT/ET 0.35 on all-cause mortality was retrospectively studied. During a median follow-up of 39 (25th-75th percentile, 23-62) months, 70 patients died. AT/ET >0.35 was associated with a considerable increased mortality risk after adjustment for established prognostic factors in SAS under medical and/or surgical management (adjusted hazard ratio [HR], 2.54; 95% CI, 1.47-4.37; P0.35 improved the predictive performance of models including established risk factors in SAS with better global model fit, reclassification, and discrimination. After propensity matching, increased mortality risk persisted when AT/ET >0.35 (adjusted HR, 2.10; 95% CI, 1.12-3.90; P0.35 is a strong predictor of outcome in patients with SAS and no or only mild symptoms and identifies a subgroup of patients at higher risk of death who may derive benefit from earlier aortic valve replacement

Impact of pulmonary hypertension on long-term outcome in patients with severe aortic stenosis

International audienceAims Pulmonary hypertension (PH) is common in severe symptomatic left- sided valvular disease, particularly in aging populations. Inconsistent results have been reported concerning the association between PH and adverse outcomes after aortic valve replacement for aortic stenosis (AS). We therefore retrospectively investigated the prognostic significance of PH using peak tricuspid regurgitation velocity (TRV), as defined by the current European Society of Cardiology (ESC)/European Respiratory Society (ERS) guidelines, in a large cohort of patients with severe AS. Methods and results One thousand and nineteen patients (541 men; mean age 74 +/- 11 years) with severe AS (aortic valve area (AVA) = 50% were included. Patients were divided into three groups according to the level of their peak TRV at the time of enrolment: Group 1 (n = 695, 68%) when TRV was 3.4 m/s. Median overall follow-up was 31 [6-182] months. On univariate analysis, overall mortality during follow-up was globally different between groups (P 3.4 m/s) exhibited significant excess mortality after adjustment for covariates of prognostic importance (P = 0.032) and after further adjustment for surgery (P = 0.012), using Group 1 as the reference group. Dividing the whole population into two groups with a 3.4 m/s TRV threshold, overall mortality during follow-up was higher in the PH group [hazard ratio (HR) 1.87; 95% confidence interval [1.37-2.56]; P < 0.001)]. On multivariate analysis, after covariate adjustment, including surgery, Group 3 exhibited major excess mortality (adjusted HR 1.46 [1.10-1.95], P = 0.009). Conclusion This study demonstrates the negative impact of pulmonary pressure, as assessed by current ESC/ERS guidelines, on long-term outcome of patients with severe AS, irrespective of functional status, chronic obstructive pulmonary disease, AS severity and surgery. Baseline TRV should therefore be taken into account in the management of severe AS

Correction: Asymptomatic aortic stenosis: An assessment of patients' and of their general practitioners' knowledge, after an indexed specialized assessment in community practice.

[This corrects the article DOI: 10.1371/journal.pone.0179988.]

Relationship between exercise pressure gradient and haemodynamic progression of aortic stenosis

International audienceBackground and aims. - We hypothesized that large exercise-induced increases in aortic mean pressure gradient can predict haemodynamic progression during follow-up in asymptomatic patients with aortic stenosis. Methods. - We retrospectively identified patients with asymptomatic moderate or severe aortic stenosis (aortic valve area 20 mmHg) as compared to those with exercise-induced increase in aortic mean pressure gradient < 20 mmHg (median annualised increase in mean pressure gradient 19 [6-28] vs. 4 [2-10] mmHg/y respectively, P=0.002). Similar results were found in the subgroup of 30 patients with moderate aortic stenosis. Conclusion. - Large exercise-induced increases in aortic mean pressure gradient correlate with haemodynamic progression of stenosis during follow-up in patients with asymptomatic aortic stenosis. Further studies are needed to fully establish the role of ESE in the decision-making process in comparison to other prognostic markers in asymptomatic patients with aortic stenosis. (C) 2017 Elsevier Masson SAS. All rights reserved

Clinical significance of energy loss index in patients with low-gradient severe aortic stenosis and preserved ejection fraction

We hypothesized that among patients with low-gradient severe aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF), reclassification of AS severity as moderate by pressure recovery adjusted indexed aortic valve area (AVAi) = energy loss index (ELI), may identify a subgroup of patients with a better outcome.; Three hundred and seventy-nine patients with low-gradient AS (defined by AVAi ≤ 0.6 cm2/m2 and mean aortic pressure gradient 0.6 cm2/m2. Cardiac events [cardiac mortality and/or need for aortic valve replacement (AVR)] during follow-up were studied. One hundred and forty-eight patients (39%) were reclassified as moderate AS by ELI. Reclassification as moderate AS was independently associated with decreased body surface area, normal flow status, decreased left ventricular mass index, and left atrial volume index (all P < 0.05). After adjustment for variables of prognostic interest, reclassification as moderate AS by ELI was associated with a considerable reduction of risk of cardiac events {adjusted hazard ratio (HR) 0.49 [95% confidence interval (CI) 0.33-0.72]; P < 0.001}, need for AVR [adjusted HR 0.52 (95% CI 0.34-0.81); P = 0.004], and cardiac mortality [adjusted HR 0.46 (95% CI 0.22-0.98); P = 0.044].; In patients with low-gradient severe AS and preserved LVEF, calculation of ELI permits to reclassify almost 40% of patients as having moderate AS. These reclassified patients have a considerable reduction of the risk of cardiac events during follow-up. Calculation of ELI is useful for decision-making in patients with low-gradient severe AS and preserved ejection fraction