Risk Prediction in Aortic Valve Replacement: Incremental Value of the Preoperative Echocardiogram.
BACKGROUND
Risk prediction is a critical step in patient selection for aortic valve replacement (AVR), yet existing risk scores incorporate very few echocardiographic parameters. We sought to evaluate the incremental predictive value of a complete echocardiogram to identify high-risk surgical candidates before AVR.


RESULTS
A cohort of patients with severe aortic stenosis undergoing surgical AVR with or without coronary bypass was assembled at 2 tertiary centers. Preoperative echocardiograms were reviewed by independent observers to quantify chamber size/function and valve function. Patient databases were queried to extract clinical data. The cohort consisted of 432 patients with a mean age of 73.5 years and 38.7% females. Multivariable logistic regression revealed 3 echocardiographic predictors of in-hospital mortality or major morbidity: E/e' ratio reflective of elevated left ventricular (LV) filling pressure; myocardial performance index reflective of right ventricular (RV) dysfunction; and small LV end-diastolic cavity size. Addition of these echocardiographic parameters to the STS risk score led to an integrated discrimination improvement of 4.1% (P<0.0001). After a median follow-up of 2 years, Cox regression revealed 5 echocardiographic predictors of all-cause mortality: small LV end-diastolic cavity size; LV mass index; mitral regurgitation grade; right atrial area index; and mean aortic gradient <40 mm Hg.


CONCLUSIONS
Echocardiographic measures of LV diastolic dysfunction and RV performance add incremental value to the STS risk score and should be integrated in prediction when evaluating the risk of AVR. In addition, findings of small hypertrophied LV cavities and/or low mean aortic gradients confer a higher risk of 2-year mortality.
Massachusetts General Hospital, Harvard Medical School, Boston, MA (T.C.T., A.W.F., P.M., M.C.N., L.M.R., D.M.S., M.H.P., J.A.).
Timothy C
TC
Tan
Massachusetts General Hospital, Harvard Medical School, Boston, MA (T.C.T., A.W.F., P.M., M.C.N., L.M.R., D.M.S., M.H.P., J.A.) Hartford Hospital, University of Connecticut, Hartford, CT (A.W.F.).
Aidan W
AW
Flynn
Jewish General Hospital, McGill University, Montreal, Quebec, Canada (A.C.T., L.G.R., J.A.).
Annabel
A
Chen-Tournoux
Jewish General Hospital, McGill University, Montreal, Quebec, Canada (A.C.T., L.G.R., J.A.).
Lawrence G
LG
Rudski
Massachusetts General Hospital, Harvard Medical School, Boston, MA (T.C.T., A.W.F., P.M., M.C.N., L.M.R., D.M.S., M.H.P., J.A.) Thomas Jefferson University Hospital, Jefferson Medical College, Philadelphia, PA (P.M.).
Praveen
P
Mehrotra
Massachusetts General Hospital, Harvard Medical School, Boston, MA (T.C.T., A.W.F., P.M., M.C.N., L.M.R., D.M.S., M.H.P., J.A.) Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil (M.C.N.).
Maria C
MC
Nunes
Massachusetts General Hospital, Harvard Medical School, Boston, MA (T.C.T., A.W.F., P.M., M.C.N., L.M.R., D.M.S., M.H.P., J.A.).
Luis M
LM
Rincon
Massachusetts General Hospital, Harvard Medical School, Boston, MA (T.C.T., A.W.F., P.M., M.C.N., L.M.R., D.M.S., M.H.P., J.A.).
David M
DM
Shahian
Massachusetts General Hospital, Harvard Medical School, Boston, MA (T.C.T., A.W.F., P.M., M.C.N., L.M.R., D.M.S., M.H.P., J.A.).
Michael H
MH
Picard
Massachusetts General Hospital, Harvard Medical School, Boston, MA (T.C.T., A.W.F., P.M., M.C.N., L.M.R., D.M.S., M.H.P., J.A.) Jewish General Hospital, McGill University, Montreal, Quebec, Canada (A.C.T., L.G.R., J.A.) Centre for Clinical Epidemiology, Lady Davis Institute, Montreal, Quebec, Canada (J.A.).
Jonathan
J
Afilalo
D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging* / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001900:Boston; D015150:Echocardiography, Doppler; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects* / Q000401:mortality; D006801:Humans; D017379:Hypertrophy, Left Ventricular / Q000000981:diagnostic imaging / Q000503:physiopathology; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009200:Myocardial Contraction; D016017:Odds Ratio; D018579:Patient Selection; D011237:Predictive Value of Tests; D011300:Preoperative Care / Q000379:methods*; D016016:Proportional Hazards Models; D011792:Quebec; D020127:Recovery of Function; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D062606:Tertiary Care Centers; D013997:Time Factors; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging / Q000503:physiopathology; D016277:Ventricular Function, Left; D016278:Ventricular Function, Right; D017725:Ventricular Pressure
aortic stenosis; aortic valve replacement; echocardiography; outcomes