Prognostication and Interventional Guidance Using Acceleration-Ejection Time Ratio in Undifferentiated Paradoxical Low-Flow Low-Gradient Aortic Stenosis.

Autor:	Chong A; Princess Alexandra Hospital, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia., Sen J; Princess Alexandra Hospital, Brisbane, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia; Department of Cardiometabolic Health, University of Melbourne, Melbourne, Australia., Reyaldeen R; Princess Alexandra Hospital, Brisbane, Australia., Wahi S; Princess Alexandra Hospital, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia., Huynh Q; Baker Heart and Diabetes Institute, Melbourne, Australia; Monash University Alfred Health, Melbourne, Australia., Wang WYS; Princess Alexandra Hospital, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia., Marwick TH; Baker Heart and Diabetes Institute, Melbourne, Australia; Department of Cardiometabolic Health, University of Melbourne, Melbourne, Australia. Electronic address: tom.marwick@baker.edu.au.
Jazyk:	angličtina
Zdroj:	JACC. Cardiovascular imaging [JACC Cardiovasc Imaging] 2024 Nov; Vol. 17 (11), pp. 1290-1301. Date of Electronic Publication: 2024 Aug 14.
DOI:	10.1016/j.jcmg.2024.05.015
Abstrakt:	Background: Studies in paradoxical low-flow low-gradient aortic stenosis (PLFAS) have demonstrated conflicting outcomes with variable survival advantage from aortic valve replacement (AVR). PLFAS is a heterogeneous composition of patients with uncertainty regarding true stenosis severity that continues to confound decision-making for AVR. Objectives: The purpose of this study was to investigate the utility of the Doppler acceleration (AT) to ejection (ET) time ratio (AT:ET) for prediction of prognosis and benefit from AVR in undifferentiated PLFAS. Methods: Patients with echocardiographic findings of PLFAS (aortic valve area <1.0 cm 2 or indexed aortic valve area <0.6 cm 2 /m 2 , mean gradient <40 mm Hg, indexed stroke volume <35 mL/m 2 , and left ventricular ejection fraction ≥50%) were identified and grouped according to an AT:ET cutoff of 0.35. The primary outcome was a 5-year composite of cardiac mortality or AVR. Secondary outcomes included the individual components of the primary endpoint and all-cause mortality at 5 years. Effect of AVR was analyzed in the AT:ET <0.35 and ≥0.35 groups. Results: A total of 171 PLFAS patients (median age 77.0 years, 57% women) were followed for a median of 8.9 years. AT:ET ≥0.35 was an independent predictor of the primary outcome (HR: 4.77 [95% CI: 2.94-7.75]; P < 0.001) with incremental value over standard indices of stenosis severity (net reclassification improvement: 0.57 [95% CI: 0.14-0.84]). AT:ET ≥0.35 also remained predictive of increased cardiac death (HR: 2.91 [95% CI: 1.47-5.76]; P = 0.002) and AVR (HR: 8.45 [95% CI: 4.16-17.1]; P < 0.001), respectively, following competing risk analysis. No difference in all-cause mortality was observed. AVR in the AT:ET ≥0.35 group was associated with significant reductions in 5-year cardiac (HR: 0.09 [95% CI: 0.02-0.36]; P < 0.001) and all-cause mortality (HR: 0.16 [95% CI: 0.07-0.38]; P < 0.001). No improvement in survival from AVR was demonstrated in AT:ET <0.35 patients. Conclusions: AT:ET ≥0.35 in PLFAS predicts poorer outcomes and/or need for AVR. In undifferentiated PLFAS patients, AT:ET may have a potential role in improving patient selection for prognostic AVR. Competing Interests: Funding Support and Author Disclosures Dr Sen is supported by scholarships from the National Heart Foundation of Australia (ID: 102578), National Health and Medical Research Council of Australia (ID: 1191044), Baker Heart and Diabetes Institute (Bright Sparks), and the Australian Government Research Training Program. Dr Marwick is supported by an Investigator Grant from the National Heart Foundation of Australia (2008129). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)
Databáze:	MEDLINE
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