Brunilda Alushi1,2, Stephan Ensminger3, Eva Herrmann4,5, Ümniye Balaban4,5, Timm Bauer6, Andreas Beckmann7, Sabine Bleiziffer8, Helge Möllmann9, Thomas Walther10, Raffi Bekeredjian11, Christian Hamm12, Friedhelm Beyersdorf13, Stephan Baldus14, Andreas Boening15, Volkmar Falk16,17, Holger Thiele18, Christian Frerker19, Alexander Lauten20,16. 1. Department of Cardiovascular Diseases, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin and German Centre for Cardiovascular Research (DZHK) Berlin Site, Hindenburgdamm 30, 12200, Berlin, Germany. brunilda.alushi@charite.de. 2. Department of Internal Medicine and Cardiology, Zollernalbklinik, Balingen, Germany. brunilda.alushi@charite.de. 3. Department of Cardiac and Thoracic Vascular Surgery, University Heart Center Lübeck, Lübeck, Germany. 4. Institute of Biostatistics and Mathematical Modelling at Goethe University, Frankfurt am Main, Germany. 5. German Center for Cardiovascular Research, (DZHK), Partner Site Rhine Main, Frankfurt am Main, Germany. 6. Department of Cardiology, Sana Klinikum Offenbach, Offenbach, Germany. 7. German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany. 8. Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr Universität Bochum, Bad Oeynhausen, Germany. 9. Medizinische Klinik I, St.-Johannes-Hospital Dortmund, Dortmund, Germany. 10. Department of Cardiac Surgery, Goethe University Hospital, Frankfurt am Main, Germany. 11. Department of Cardiology, Robert-Bosch-Hospital, Stuttgart, Germany. 12. Department of Cardiology, University Clinic Giessen, Giessen, Germany. 13. Department of Cardiovascular Surgery, University Heart Centre Bad Krozingen, Freiburg, Germany. 14. Department of Cardiology, Koeln University Hospital, Koeln, Germany. 15. Department of Thorax and Cardiovascular Surgery, University Clinic Giessen, Giessen, Germany. 16. Department of Interventional Cardiology, Helios Klinikum Erfurt, Erfurt, Germany. 17. Department of Cardiothoracic Surgery, Charité - Universitätsmedizin Berlin Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany. 18. Department of Cardiology, Heart Center Leipzig at University Leipzig and Leipzig Heart Institute, Leipzig, Germany. 19. II. Department of Medicine, University Medical Center Schleswig-Holstein, Lübeck, Germany. 20. Department of Cardiovascular Diseases, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin and German Centre for Cardiovascular Research (DZHK) Berlin Site, Hindenburgdamm 30, 12200, Berlin, Germany.
Abstract
BACKGROUND: Patients with severe aortic stenosis (AS) frequently presented mitral regurgitation (MR), which may interfere with the standard echocardiographic measurements of mean pressure gradient (MPG), flow velocity, and aortic valve area (AVA). AIMS: Herein we investigated the prevalence and severity of MR in patients with severe AS and its role on the accuracy of the standard echocardiographic parameters of AS quantification. METHODS: Of all patients with severe AS undergoing transcatheter or surgical aortic valve replacement enrolled in the German Aortic Registry from 2011 to 2017, 119,641 were included in this study. The population was divided based on the values of left ventricular ejection fraction ([LVEF] > 50%, LVEF 31-50%, and LVEF ≤ 30%] and AVA (0.80 to ≤ 1.00 cm2, 0.60 to < 0.80 cm2, 0.40 to < 0.60 cm2, and 0.20 to < 0.40 cm2). RESULTS: Overall, 77,890 (65%) patients with mild to-moderate and 4262 (4%) with severe MR were compared with 37,489 (31%) patients without MR. Patients with mild-to-moderate and severe MR presented significantly lower mPG (ΔmPG [95%CI] - 1.694 mmHg [- 2.123 to - 1.265], p < 0.0001 and - 6.954 mmHg [- 7.725 to - 6.183], p < 0.0001, respectively), that increased with LVEF impairment. Conversely, AVA did not differ (severe versus no MR: ΔAVA [95%CI]: - 0.007cm2 [- 0.023 to 0.009], p = 0.973). Increasing MR severity was associated with significant mPG reduction throughout all AVA strata, causing a low-gradient pattern, that manifested since the early stages of severe AS (LVEF > 50%: AVA 0.80 to 1.00 cm2; LVEF 31-50%: AVA 0.60 to 0.80 cm2). CONCLUSIONS: In patients with severe AS, concomitant MR is common, contributes to the onset of a low-gradient AS pattern, and affects the diagnostic accuracy of flow-dependent AVA measurements. In this setting, a multimodality, AVA-centric approach should be implemented. In patients with severe aortic stenosis, concomitant mitral regurgitation contributes to the onset of a low-gradient pattern, warranting a multimodality, and AVA-centric diagnostic approach.
BACKGROUND: Patients with severe aortic stenosis (AS) frequently presented mitral regurgitation (MR), which may interfere with the standard echocardiographic measurements of mean pressure gradient (MPG), flow velocity, and aortic valve area (AVA). AIMS: Herein we investigated the prevalence and severity of MR in patients with severe AS and its role on the accuracy of the standard echocardiographic parameters of AS quantification. METHODS: Of all patients with severe AS undergoing transcatheter or surgical aortic valve replacement enrolled in the German Aortic Registry from 2011 to 2017, 119,641 were included in this study. The population was divided based on the values of left ventricular ejection fraction ([LVEF] > 50%, LVEF 31-50%, and LVEF ≤ 30%] and AVA (0.80 to ≤ 1.00 cm2, 0.60 to < 0.80 cm2, 0.40 to < 0.60 cm2, and 0.20 to < 0.40 cm2). RESULTS: Overall, 77,890 (65%) patients with mild to-moderate and 4262 (4%) with severe MR were compared with 37,489 (31%) patients without MR. Patients with mild-to-moderate and severe MR presented significantly lower mPG (ΔmPG [95%CI] - 1.694 mmHg [- 2.123 to - 1.265], p < 0.0001 and - 6.954 mmHg [- 7.725 to - 6.183], p < 0.0001, respectively), that increased with LVEF impairment. Conversely, AVA did not differ (severe versus no MR: ΔAVA [95%CI]: - 0.007cm2 [- 0.023 to 0.009], p = 0.973). Increasing MR severity was associated with significant mPG reduction throughout all AVA strata, causing a low-gradient pattern, that manifested since the early stages of severe AS (LVEF > 50%: AVA 0.80 to 1.00 cm2; LVEF 31-50%: AVA 0.60 to 0.80 cm2). CONCLUSIONS: In patients with severe AS, concomitant MR is common, contributes to the onset of a low-gradient AS pattern, and affects the diagnostic accuracy of flow-dependent AVA measurements. In this setting, a multimodality, AVA-centric approach should be implemented. In patients with severe aortic stenosis, concomitant mitral regurgitation contributes to the onset of a low-gradient pattern, warranting a multimodality, and AVA-centric diagnostic approach.
Authors: Catherine M Otto; Rick A Nishimura; Robert O Bonow; Blase A Carabello; John P Erwin; Federico Gentile; Hani Jneid; Eric V Krieger; Michael Mack; Christopher McLeod; Patrick T O'Gara; Vera H Rigolin; Thoralf M Sundt; Annemarie Thompson; Christopher Toly Journal: Circulation Date: 2020-12-17 Impact factor: 29.690