Global left ventricular (LV) afterload as assessed by valvulo-arterial impedance (Zva), may be an independent predictor of mortality in patients with severe aortic stenosis (AS) and preserved LV ejection fraction (LVEF). However, its quantification using echocardiography may be subject to error measurement.
We aimed to determine the prevalence and impact on long-term survival of high Zva, purposely measured by cardiac catheterization.
Methods and results
676 patients with preserved LVEF and severe AS without other valvular heart diseases underwent cardiac catheterization. Zva was derived from catheterization and calculated as follows: mean aortic gradient + systolic blood pressure/indexed LV stroke volume. Zva was considered high when >5 mm Hg/mL/m2 based on previous studies.
Overall, high Zva was found in 42% of all AS patients. Four-year survival and 8-year survival were significantly reduced in patients with high Zva (74 ± 3% and 57 ± 4%) as compared to those with low Zva (85 ± 2% and 74 ± 3%; p = 0.002). After adjustment for all other risk factors, Zva was independently associated with reduced long-term survival (hazard ratio [HR] = 1.47 95% CI: 1.04–2.09; p = 0.029). Of interest, high Zva remained associated with reduced survival as compared to low Zva, in patients with normal LV stroke volume, but was no longer significant in low flow patients (p = 0.98).
High Zva, estimated invasively in our study, is frequent in patients with severe AS, and appears as a robust and independent predictor of survival. Zva should be used as an additional parameter for risk stratification of severe AS, more particularly in patients with normal flow.
To read this article in full you will need to make a payment
Purchase one-time access:Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
One-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:Subscribe to International Journal of Cardiology
Already a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
- Clinical factors associated with calcific aortic valve disease. Cardiovascular Health Study.J. Am. Coll. Cardiol. 1997; 29: 630-634
- 2014 AHA/ACC Guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines.Circulation. 2014; 129: e521-e643
- Guidelines on the management of valvular heart disease (version, the joint task force on the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS).Eur. Heart J. 2012; 2012: 2451-2496
- Should severe aortic stenosis be operated on before symptom onset? Aortic valve replacement should be operated on before symptom onset.Circulation. 2012; 126: 112-117
- Should severe aortic stenosis be operated on before symptom onset? Severe aortic stenosis should not be operated on before symptom onset.Circulation. 2012; 126: 118-125
- Reduced systemic arterial compliance impacts significantly on left ventricular afterload and function in aortic stenosis: implications for diagnosis and treatment.J. Am. Coll. Cardiol. 2005; 46: 291-298
- Impact of global hemodynamic load on exercise capacity in aortic stenosis.Int. J. Cardiol. 2013; 168: 2272-2277
- Usefulness of the valvuloarterial impedance to predict adverse outcome in asymptomatic aortic stenosis.J. Am. Coll. Cardiol. 2009; 54: 1003-1011
- Risk stratification in asymptomatic moderate to severe aortic stenosis: the importance of the valvular, arterial and ventricular interplay.Heart. 2010; 96: 1364-1371
- Association of myocardial deformation with outcome in asymptomatic aortic stenosis with normal ejection fraction.Circ. Cardiovasc. Imaging. 2012; 5: 719-725
- Valvuloarterial impedance in aortic stenosis: look at the load, but do not forget the flow.Eur. J. Echocardiogr. 2011; 12: 354-357
- Outcome and impact of surgery in paradoxical low-flow, low-gradient severe aortic stenosis and preserved left ventricular ejection fraction: a cardiac catheterization study.Circulation. 2013; 128: S235-S242
- Symptomatic aortic stenosis: does systemic hypertension play an additional role?.Hypertension. 2003; 41: 1268-1272
- Improving assessment of aortic stenosis.J. Am. Coll. Cardiol. 2012; 60: 169-180
- Low-flow aortic stenosis in asymptomatic patients: valvular–arterial impedance and systolic function from the SEAS Substudy.JACC Cardiovasc. Imaging. 2009; 2: 390-399
- Impact of global left ventricular afterload on left ventricular function in asymptomatic severe aortic stenosis: a two-dimensional speckle-tracking study.Eur. J. Echocardiogr. 2010; 11: 537-543
- Prognostic significance of valvuloarterial impedance and left ventricular longitudinal function in asymptomatic severe aortic stenosis involving three-cuspid valves.Am. J. Cardiol. 2011; 108: 1463-1469
- Valvuloarterial impedance, but not aortic stenosis severity, predicts syncope in patients with aortic stenosis.Circ. Cardiovasc. Imaging. 2013; 6: 1024-1031
- Impact of valvuloarterial impedance on 2-year outcome of patients undergoing transcatheter aortic valve implantation.J. Am. Soc. Echocardiogr. 2013; 26: 691-698
- Global left ventricular load in asymptomatic aortic stenosis: covariates and prognostic implication (the SEAS trial).Cardiovasc. Ultrasound. 2012; 10: 43
- ESC working group on valvular heart disease position paper–heart valve clinics: organization, structure, and experiences.Eur. Heart J. 2013; 34: 1597-1606
- Valvuloarterial impedance does not improve risk stratification in low-ejection fraction, low-gradient aortic stenosis: results from a multicentre study.Eur. J. Echocardiogr. 2011; 12: 358-363
- Predictors of mortality and outcomes of therapy in low-flow severe aortic stenosis: a Placement of Aortic Transcatheter Valves (PARTNER) trial analysis.Circulation. 2013; 127: 2316-2326
- Impact of low flow on the outcome of high-risk patients undergoing transcatheter aortic valve replacement.J. Am. Coll. Cardiol. 2013; 62: 782-788
Published online: November 26, 2014
Accepted: November 23, 2014
Received: October 8, 2014
© 2014 Elsevier Ireland Ltd. Published by Elsevier Inc. All rights reserved.