Acute Valve Syndrome in Aortic Stenosis

Abstract

Background: To describe the impact of clinical presentation among patients with aortic stenosis (AS) undergoing aortic valve replacement (AVR).

Methods: We analyzed a real-world dataset including patients from 29 US hospitals (egnite Database, egnite). Patients over 18 years old with moderate or greater AS undergoing AVR were included. Patients were classified into 3 groups according to the acuity and severity of clinical presentation prior to AVR: (i) asymptomatic, (ii) progressive signs and symptoms (progressive valve syndrome [PVS]), and (iii) acute or advanced signs and symptoms (acute valve syndrome [AVS]). Mortality and heart failure hospitalization after AVR were examined with Kaplan-Meier estimates, with results compared using the log-rank test.

Results: Among 2,009,607 patients in our database, 17,838 underwent AVR (78.6% transcatheter AVR, 21.4% surgical AVR). Age was 76.5 ± 9.7 years, and 40.2% were female. Prior to AVR, 2504 (14.0%) were asymptomatic, 6116 (34.3%) presented with PVS, and 9218 (51.7%) presented with AVS. At 2 years, the estimated rate of mortality for asymptomatic, PVS, and AVS were 5.8% (4.6%-7.0%), 7.6% (6.7%-8.4%), and 17.5% (16.5%-18.5%), respectively, and the estimated rate of hospitalization with heart failure for asymptomatic, PVS, and AVS were 11.1% (9.5%-12.6%), 19.0% (17.8%-20.2%), and 41.5% (40.2%-42.8%), respectively. After adjustment, patients presenting with AVS had increased risk of mortality after AVR (hazard ratio, 2.2; 95% CI, 1.8-2.6).

Conclusions: From a large, real-world database of patients undergoing AVR for AS, most patients presented with AVS, which was associated with an increased risk of mortality and heart failure hospitalization.

Keywords: Aortic stenosis; Aortic valve; Aortic valve replacement; Clinical presentation; Transcatheter aortic valve implantation; Transcatheter aortic valve replacement.

Graphical abstract

Figure 1

Study flow chart. Among 2,009,607 patients from 29 US institutions in the egnite Database (egnite), 17,838 patients with at least moderate aortic stenosis (AS) and undergoing aortic valve replacement (AVR) were included in our study. Patients were stratified in 3 groups based on the worst clinical presentation within 6 months prior to AVR: (i) asymptomatic, with no signs or symptoms, (ii) progressive signs or symptoms of AS (PVS), including: New York Heart Association (NYHA) class II (dyspnea, fatigue, dizziness, angina) edema, diastolic heart failure, and elevated natriuretic peptide defined as 100 pg/mL < BNP <400 pg/mL and/or 1000 pg/mL < NT-proBNP <1500 pg/mL, (iii) acute or advanced signs and symptoms of AS (AVS), including: NYHA class III-IV (any of admission with heart failure, pulmonary edema, or syncope), left ventricle ejection fraction <50% by echocardiogram, systolic heart failure, high natriuretic peptide defined as BNP ≥400 pg/mL and/or NT-proBNP ≥1500 pg/mL, new-onset atrial fibrillation, hypotension, cardiogenic shock, new-onset ventricular arrhythmia, resuscitation from cardiac arrest, or endocarditis. Abbreviations: AR, aortic regurgitation; AVS, acute valve syndrome; BNP, B-type natriuretic peptide; NT-proBNP, N-terminal pro-B-type natriuretic peptide; PVS, progressive valve syndrome.

Figure 2

Two-year outcomes after aortic valve replacement (AVR) per clinical presentation. Two-year outcomes after AVR according to clinical presentation before AVR among patients with at least moderate aortic stenosis. (a) Two-year mortality after AVR per clinical presentation before AVR. (b) Two-year hospitalization with heart failure after AVR per clinical presentation before AVR. (c) Two-year mortality or hospitalization with heart failure after AVR per clinical presentation before AVR.

Figure 3

Multiple variable analysis for 2-year outcomes after aortic valve replacement. Two-year outcomes adjusted for age, sex, comorbidities, and clinical presentation before aortic valve replacement. (a) Mortality; (b) hospitalization for heart failure; (c) composite of mortality or hospitalization with heart failure. Abbreviation: COPD, chronic obstructive pulmonary disease; HR, hazard ratio.