Is diastolic dysfunction a red flag sign in moderate aortic stenosis?

With rapidly ageing population, aortic stenosis (AS) has become one of the most common valvular heart diseases. Severe AS is clearly associated with increased mortality, and the current American College of Cardiology/American Heart Association guidelines designate a class I or IIa indication for aortic valve surgery in severe patients with AS with symptoms or with low left ventricular (LV) function.1 Historically, based on the lower risk of sudden death in moderate AS compared with severe AS, watchful observation was recommended to patients with moderate AS. In the last decade, prognostic findings on moderate AS have been gathered (table 1).2–4 A large echocardiographic national database study, including 3315 moderate AS with various LV systolic functions, suggested a poor survival rate (5-year mortality: 56%).4 Recently, two academic institutional databases, including 1245 moderate AS, also showed poor prognosis during follow-up (median follow-up: 4.3 years; mortality: 45.3%).3

View this table:

Table 1

Prognosis of moderate aortic stenosis

From a physiological viewpoint, narrowing of the aortic valve area leads to LV systolic/diastolic dysfunction due to LV pressure overloading. In patients with severe AS who particularly underwent transcatheter aortic valve replacement (TAVR), diastolic dysfunction (DD) has been described as an early marker of myocardial damage and an important prognostic information. Thaden et al
5 reported an association between echocardiographic data and outcomes from a retrospective single-centre study. Over a mean follow-up period of 7.3 years, increased left atrial pressure based on the American Society of Echocardiography/European Association of Cardiovascular Imaging criteria remained an independent predictor of mortality after successful aortic valve replacement …

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