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Invasive Hemodynamic Staging Classification of Cardiac Damage in Patients With Aortic Stenosis Undergoing Valve Replacement

Journal Paper/Review - Feb 8, 2020

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Citation
Maeder M, Maisano F, Ehl N, Buser M, Taramasso M, Jörg L, Haager P, Weilenmann D, Weber L, Rickli H. Invasive Hemodynamic Staging Classification of Cardiac Damage in Patients With Aortic Stenosis Undergoing Valve Replacement. Can J Cardiol 2020
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Journal Paper/Review (English)
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Can J Cardiol 2020
Publication Date
Feb 8, 2020
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1916-7075
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BACKGROUND
An echocardiographic 5-stage classification of cardiac damage in aortic stenosis (AS) has been shown to provide prognostic information. We aimed to create an analogous classification based on invasive hemodynamics.

METHODS
We studied 421 patients (age 75 ± 10 years, 59% men) with severe AS with complete invasive hemodynamics obtained before aortic valve replacement (AVR). Cardiac damage stages were defined as follows: stage 0, absence of any of the following criteria; stage 1, left-ventricular end-diastolic pressure >15 mm Hg; stage 2, mean pulmonary artery wedge pressure > 15 mm Hg; stage 3, pulmonary vascular resistance > 3 Wood units and/or systolic pulmonary artery pressure > 60 mm Hg; stage 4, mean right atrial pressure >15 mm Hg. Patients were hierarchically classified in a given stage (worst stage) if the criterion was met for that stage.

RESULTS
Sixty-seven (16%) patients were classified as stage 0, 113 (27%) as stage 1, 151 (36%) as stage 2, 73 (17%) as stage 3, and 17 (4%) as stage 4. After a median (interquartile range) follow-up of 3.8 (2.7 to 5.2) years after AVR, mortality was highest in stage 4 (hazard ratio; 95% confidence interval: 6.17 (1.74-21.89) vs stage 0; P = 0.005 and stage 3 patients (hazard ratio; 95% confidence interval: 4.17 (1.39-12.49) vs stage 0; P = 0.01,whereas mortality did not differ between patients in stages 0 to 2.

CONCLUSIONS
A staging system of cardiac damage based on invasive hemodynamic parameters in patients with severe AS undergoing AVR predicts mortality. Pulmonary vascular disease and high right-atrial pressure are the major drivers of mortality.