Patrick O’Neill-González

Background/Objectives: In patients with severe aortic stenosis (AS), extra valvular cardiac damage is associated with outcomes following intervention. We aimed to analyze differences in AS-related cardiac damage between surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) patients in a contemporary cohort of patients with severe AS. Methods: Patients who underwent SAVR or TAVR in a tertiary care center from 2017 to 2022 were included in this retrospective analysis. Clinical and echocardiographic parameters before surgery were compared, and patients were classified according to two available cardiac damage staging systems. Additionally, all-cause mortality 1-year post-intervention was assessed according to these stages. Results: Eight hundred and seventy-four patients were included (524 underwent TAVR and 350 underwent SAVR). TAVR patients were significantly older (81.9 ± 6.1 vs. 69.5 ± 9.5 years; p < 0.001), more commonly female (52.4% vs. 37.7%; p < 0.001), and had higher surgical risk (EuroSCORE II 6.2 ± 7.0 vs. 2.7 ±3.3; p < 0.001). Compared with SAVR, patients treated with TAVR had significantly more advanced (right-sided) cardiac damage, both with Généreux (37.8% vs. 23.1%; p < 0.001) and Gutiérrez-Ortiz (16.5% vs. 9.0%; p = 0.007) staging systems. Moreover, regardless of the type of intervention or the staging system used, mortality was significantly higher in patients with right-sided damage. Conclusions: In a contemporary cohort of severe symptomatic AS patients, those treated with TAVR had significantly more extensive cardiac damage compared with those who underwent SAVR. This finding raises the question of when to intervene in patients chosen for TAVR. Earlier intervention, before advanced cardiac damage ensues, might help to improve outcomes.

Background: Several cardiac damage staging systems for aortic stenosis (AS) have been proposed, but their usefulness in patients undergoing surgical aortic valve replacement (SAVR) remains unknown. Objectives: We aim to externally validate two staging systems in patients who underwent SAVR. Methods: Single-centre prospective cohort of patients treated with SAVR (2017–2022). Based on baseline echocardiographic parameters, patients were classified into the different stages of two published staging systems (Généreux et al. and Gutiérrez et al.), and the discriminatory yield of these systems for 1-year mortality was evaluated. Results: In total, 350 patients were analysed (mean age 69 (9.4) years, 37.8% were female). The median EuroSCORE II was 1.7 (1.1–3.1), and 1-year mortality occurred in 17 (4.8%) patients. The staging system developed by Gutiérrez et al. had an area under the ROC curve (AUC) of 0.687 (95% CI: 0.571–0.803) and was superior to Généreux et al.’s system (AUC of 0.554; 95% CI: 0.439–0.669; p = 0.008). Applying Gutiérrez et al.’s system, 1-year mortality rates progressively increased with higher damage staging: 1.9% (2/103) for Stage 0; 5.1% (5/175) for Stage 1; 12.5% (5/40) for Stage 2; and 15.6% (5/32) for Stage 3 (which represents right-sided damage measured by right ventricular–arterial coupling (RVAc); p= 0.038). No significant differences in outcomes between stages were found when using the staging proposed by Généreux et al. (p = 0.218). Conclusions: In a surgical cohort of patients with AS, a cardiac staging system that included RVAc showed greater discriminatory power for 1-year mortality. Assessing the interrelation between right ventricular function and afterload could help in better risk stratification in this context.

Background/Objectives: Severe aortic stenosis (AS) is the most frequent valvular heart disease. Models for stratifying cardiac damage associated with aortic stenosis have been developed to predict outcomes following valve replacement. However, evidence regarding morphological and functional evolution, as well as potential changes in the degree of cardiac damage, is limited. We aim to provide information on the evolution of cardiac morphology and the function of patients undergoing transcatheter aortic valve replacement (TAVR) who have been classified using a cardiac damage staging system. Methods: In total, 496 patients were included in the analysis, and were classified into four stages based on the extent of cardiac damage as follows: Stage 0, no cardiac damage: left ventricle global longitudinal strain (LV-GLS) < −17%; right ventricular–arterial coupling (RVAc) ≥ 0.35), and absence of significant mitral regurgitation (MR). Stage 1, left-sided subclinical damage: LV-GLS ≥ −17%. Stage 2, left-sided damage: significant MR. Stage 3, right-sided damage: RVAc < 0.35. Results: The mean age was 82.1 ± 5.9 years, and 53.0% were female. In total, 24.5% of patients met the criteria for Stage 0, and Stage 1 included 42.8% of patients, Stage 2 included 16.5%, and Stage 3 comprised 16.2% of patients. Mortality was 8.4% for stage 0, 17.4% for stage 1, 25.6% for stage 2, and 28.6% for stage 3 patients (p = 0.004). Diabetes mellitus (DM) (p = 0.047) and chronic kidney disease (CKD) (p = 0.024) were the only clinical predictors of no change or worsening in the stage of cardiac damage. Regarding echocardiographic variables, concomitant tricuspid, and mitral regurgitation, ≥ 2 were both significantly associated with no change or worsening, also (p < 0.001). Conclusions: Cardiac damage that is secondary to severe aortic stenosis has morphological and functional repercussions that, even after valve replacement, persist and might worsen the prognosis.