Journal of the American Society of Echocardiography
Clinical InvestigationEchocardiography in Valvular Heart DiseasesPoor Survival with Impaired Valvular Hemodynamics After Aortic Valve Replacement: The National Echo Database Australia Study
Section snippets
Study Hypotheses
We used the National Echo Database Australia (NEDA), with its capacity to individually link echocardiographic findings with long-term mortality in a large patient population.12 We first hypothesized that a prospective analysis of short- and long-term survival outcomes (including 1- and 5-year actual survival) according to residual IVH (applying the same thresholds to characterize severity of AS in those with native AVs)9,13 would confirm a gradient of increasing risk with respect to all-cause
Study Setting and Design
As described previously in our original report,12 and two recent analyses of the prognostic implications of pulmonary hypertension14 and native valve AS,8 respectively, NEDA is a very large observational registry that captures individual echocardiographic data (combined with basic demographic profiling) on a retrospective and prospective basis from participating centers throughout Australia (https://www.neda.net.au/participating-sites/). At the time of study census, a total of 12 centers had
Cohort Profile
Table 1 summarizes the broad demographic and echocardiographic characteristics of the study cohort categorized by clinical severity, comprising 3,943 men (mean age, 69 ± 16 years) and 2,107 women (mean age, 71 ± 16 years; P < .001 for age comparison). Of these, 769 (13%) underwent multiple (valve-in-valve or redo valve replacement) procedures. Overall, of the 6,050 patients, AVR function was normal (no IVH) in a total of 2,175 (36.0%; 95% CI, 34.8%–37.2%), mild IVH was seen in 2,598 (42.9%; 95%
Discussion
To our knowledge, this is the largest ever analysis of survival across the full spectrum of IVH among patients who underwent AVR, demonstrating high rates of mortality in both moderate and severe IVH when applying thresholds from current guidelines on native valvular AS.9 After adjusting for age, sex, and other potential confounders (including concurrent LV dysfunction and high- and low-flow states), those with moderate or greater IVH had a high short- and long-term risk for death (Figure 5).
Conclusion
In a very large cohort of patients who underwent prior AVR, we examined long-term survival across the spectrum of IVH and demonstrated that even moderate IVH was associated with increased rates of mortality. Importantly, the increased mortality is independent of EOA or the effects of pressure recovery. As such, we confirm that increased flow gradients across an AVR are not benign, following a similar mortality trajectory to moderate and severe native valvular AS, with a critical threshold for
Acknowledgments
We acknowledge the investigators from the NEDA contributing sites (http://www.neda.net.au/participating-sites). We gratefully acknowledge the intellectual contributions of Susan Strange in framing the concept and the term “impaired valvular hemodynamics.”
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2023, Journal of the American Society of EchocardiographyCitation Excerpt :However, whether AVR in patients with moderate AS has clinical value is uncertain. As AVR is associated with significant risks for thromboembolism, endocarditis, and structural valve deterioration,37 the risks of AVR must be weighed against the benefit of lowering transvalvular impedance to flow. Ongoing clinical trials of AVR in the setting of moderate AS, including the TAVR-UNLOAD (Transcatheter Aortic Valve Replacement to Unload the Left Ventricle in Patients With Advanced Heart Failure; NCT02661451) and PROGRESS (Management of Moderate Aortic Stenosis by Clinical Surveillance or TAVR; NCT04889872) trials will provide valuable insights into the role of nonsevere AS, as a bystander or a silent culprit,18 and whether existing treatment paradigms need reassessment.
NEDA was originally established with funding support from Actelion Australia Pharmaceuticals, Bayer Pharmaceuticals, and GlaxoSmithKline. Both NEDA (1055214) and Dr. Stewart (11358940) are supported by the National Health and Medical Research Council of Australia.
Conflicts of Interest: None.