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. 2017 Oct 31;6(11):e006615.
doi: 10.1161/JAHA.117.006615.

Left Atrial Volume and Mortality in Patients With Aortic Stenosis

Dan Rusinaru  1   2 , Yohann Bohbot  1 , Cédric Kowalski  1 , Anne Ringle  3 , Sylvestre Maréchaux  2   3 , Christophe Tribouilloy  4   2
Affiliations

Left Atrial Volume and Mortality in Patients With Aortic Stenosis

Dan Rusinaru et al. J Am Heart Assoc. .

Abstract

Background: 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/height2.0) 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/m2 compared with those with no or mild LA enlargement (both P<0.001). After adjustment for established outcome predictors, including surgery, high risk of death was observed with LAV >95 mL (adjusted hazard ratio, 1.40 [95% confidence interval, 1.06-1.88]) and LAV/BSA >50 mL/m2 (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/m2).

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.

Keywords: aortic valve stenosis; echocardiography; left atrial volume index; normalization; outcome.

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Figures

Figure 1
Figure 1
Measurement of left atrial volume from biplane method of disks (modified Simpson rule) using apical 4‐chamber (A) and apical 2‐chamber (B) views at ventricular end systole (maximum volume).
Figure 2
Figure 2
A, Kaplan‐Meier survival curves of patients with aortic stenosis (AS) according to left atrial volume (LAV) quartiles. B, Adjusted survival curves of patients with AS according to LAV quartiles. Curves are adjusted for age, sex, comorbidity, New York Heart Association class, hypertension, coronary artery disease, ejection fraction, and peak aortic jet velocity. Q1, Q2, Q3, and Q4 indicate first, second, third, and fourth quartiles, respectively.
Figure 3
Figure 3
Relationship between left atrial volume (LAV) and the risk of all‐cause death during follow‐up. Hazard ratios and 95% CIs are estimated in Cox models, with LAV represented as a spline function and adjusted for age, sex, comorbidity, New York Heart Association class, hypertension, coronary artery disease, ejection fraction, and peak aortic jet velocity.
Figure 4
Figure 4
Kaplan‐Meier survival curves of patients with moderate aortic stenosis (AS; peak aortic jet velocity [Vmax], ≤4 m/s; A) and with severe AS (Vmax, >4 m/s; B) according to left atrial volume (LAV; ≤95 and >95 mL).
Figure 5
Figure 5
A, Kaplan‐Meier survival curves of patients with aortic stenosis (AS) according to left atrial volume indexed to body surface area (LAV/BSA) quartiles. B, Adjusted survival curves of patients with AS according to LAV/BSA quartiles. Curves are adjusted for age, sex, comorbidity, New York Heart Association class, hypertension, coronary artery disease, ejection fraction, and peak aortic jet velocity. Q1, Q2, Q3, and Q4 indicate first, second, third, and fourth quartiles, respectively.
Figure 6
Figure 6
Relationship between left atrial volume indexed to body surface area (LAV/BSA) and the risk of all‐cause death during follow‐up. Hazard ratios and 95% CIs are estimated in Cox models, with LAV/BSA represented as a spline function and adjusted for age, sex, comorbidity, New York Heart Association class, hypertension, coronary artery disease, ejection fraction, and peak aortic jet velocity.
Figure 7
Figure 7
Kaplan‐Meier survival curves of patients with moderate aortic stenosis (AS; peak aortic jet velocity [Vmax], ≤4 m/s; A) and with severe AS (Vmax, >4 m/s; B) according to left atrial volume indexed to body surface area (LAV/BSA; ≤50 and >50 mL/m2).
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