title: Outcome Implication of Aortic Valve Area Normalized to Body Size in Asymptomatic Aortic Stenosis.
abstract: BACKGROUND
  Current guidelines define severe aortic stenosis in patients with aortic valve area normalized to body surface area (AVA/BSA) <0.6 cm2/m2; yet, this cutoff has never been validated. Moreover, it is not known whether AVA normalization to other body size indexes allows improved outcome prediction. We aim to test the value of AVA normalized to body size for outcome prediction in asymptomatic aortic stenosis.
  
  
  RESULTS
  We included 289 patients with asymptomatic aortic stenosis, preserved ejection fraction, and AVA<1.3 cm2at diagnosis. The outcome measure was the occurrence of aortic valve replacement or all-cause death or during follow-up. AVA was normalized to BSA, height, weight, and body mass index. For each normalized index, patients in the lowest tertile were at high risk of events whereas outcome was similar for the other tertiles. High risk of events was observed with AVA/BSA <0.4 cm2/m2(adjusted hazard ratio [HR], 3.42 [2.09-5.60]), AVA/height <0.45 cm2/m (adjusted HR, 3.99 [2.42-6.60]), AVA/weight <0.01 cm2/kg (adjusted HR, 3.37 [2.07-5.49]), and AVA/body mass index <0.029 cm2/kg per meter square (adjusted HR, 3.23 [1.99-5.24]). Mortality risk was high with AVA/height <0.45 cm2/m (adjusted HR, 2.18 [1.28-3.71]), followed by AVA/BSA <0.40 cm2/m2(adjusted HR, 1.84 [1.09-3.11]), AVA/weight <0.01 cm2/kg (adjusted HR, 1.78 [1.07-2.98]), and AVA/body mass index <0.029 cm2/kg per meter square (adjusted HR, 1.75 [1.04-2.93]). AVA/height showed better predictive performance than AVA/BSA with improved reclassification and better discrimination (net reclassification improvement: 0.33 versus 0.28; integrated discrimination improvement: 0.10 versus 0.08; C statistic: 0.67 versus 0.65), whereas AVA/weight and AVA/body mass index showed lower predictive capacity.
  
  
  CONCLUSIONS
  Among AVA normalization methods, AVA/height <0.45 cm2/m followed by AVA/BSA <0.40 cm2/m2seem as robust parameters for defining high risk in asymptomatic aortic stenosis. The prognostic value of AVA/height deserves future research.
authors.affiliation: From the Department of Cardiology (C.T., Y.B., Q.D., M.P., D.R.), Division of Clinical Research and Innovation (M.D.), and Intensive Care Unit, Department of Nephrology (M.S.), University Hospital Amiens, France; INSERM U-1088, Jules Verne University of Picardie, Amiens, France (C.T., S.M., M.S., D.R.); Groupement des Hôpitaux de l'Institut Catholique de Lille/Faculté libre de médecine, Université Lille Nord de France (S.M.); Department of Cardiology, Centre Hospitalier Universitaire de Lille, F-59000, France (N.D.) and Department of Cardiology, Cardiovascular Division, AP-HP, Bichat Hospital, Paris, France (D.M.-Z.). tribouilloy.christophe@chu-amiens.fr.
authors.forename: Christophe
authors.initials: C
authors.lastname: Tribouilloy
authors.affiliation: From the Department of Cardiology (C.T., Y.B., Q.D., M.P., D.R.), Division of Clinical Research and Innovation (M.D.), and Intensive Care Unit, Department of Nephrology (M.S.), University Hospital Amiens, France; INSERM U-1088, Jules Verne University of Picardie, Amiens, France (C.T., S.M., M.S., D.R.); Groupement des Hôpitaux de l'Institut Catholique de Lille/Faculté libre de médecine, Université Lille Nord de France (S.M.); Department of Cardiology, Centre Hospitalier Universitaire de Lille, F-59000, France (N.D.) and Department of Cardiology, Cardiovascular Division, AP-HP, Bichat Hospital, Paris, France (D.M.-Z.).
authors.forename: Yohann
authors.initials: Y
authors.lastname: Bohbot
authors.affiliation: From the Department of Cardiology (C.T., Y.B., Q.D., M.P., D.R.), Division of Clinical Research and Innovation (M.D.), and Intensive Care Unit, Department of Nephrology (M.S.), University Hospital Amiens, France; INSERM U-1088, Jules Verne University of Picardie, Amiens, France (C.T., S.M., M.S., D.R.); Groupement des Hôpitaux de l'Institut Catholique de Lille/Faculté libre de médecine, Université Lille Nord de France (S.M.); Department of Cardiology, Centre Hospitalier Universitaire de Lille, F-59000, France (N.D.) and Department of Cardiology, Cardiovascular Division, AP-HP, Bichat Hospital, Paris, France (D.M.-Z.).
authors.forename: Sylvestre
authors.initials: S
authors.lastname: Maréchaux
authors.affiliation: From the Department of Cardiology (C.T., Y.B., Q.D., M.P., D.R.), Division of Clinical Research and Innovation (M.D.), and Intensive Care Unit, Department of Nephrology (M.S.), University Hospital Amiens, France; INSERM U-1088, Jules Verne University of Picardie, Amiens, France (C.T., S.M., M.S., D.R.); Groupement des Hôpitaux de l'Institut Catholique de Lille/Faculté libre de médecine, Université Lille Nord de France (S.M.); Department of Cardiology, Centre Hospitalier Universitaire de Lille, F-59000, France (N.D.) and Department of Cardiology, Cardiovascular Division, AP-HP, Bichat Hospital, Paris, France (D.M.-Z.).
authors.forename: Nicolas
authors.initials: N
authors.lastname: Debry
authors.affiliation: From the Department of Cardiology (C.T., Y.B., Q.D., M.P., D.R.), Division of Clinical Research and Innovation (M.D.), and Intensive Care Unit, Department of Nephrology (M.S.), University Hospital Amiens, France; INSERM U-1088, Jules Verne University of Picardie, Amiens, France (C.T., S.M., M.S., D.R.); Groupement des Hôpitaux de l'Institut Catholique de Lille/Faculté libre de médecine, Université Lille Nord de France (S.M.); Department of Cardiology, Centre Hospitalier Universitaire de Lille, F-59000, France (N.D.) and Department of Cardiology, Cardiovascular Division, AP-HP, Bichat Hospital, Paris, France (D.M.-Z.).
authors.forename: Quentin
authors.initials: Q
authors.lastname: Delpierre
authors.affiliation: From the Department of Cardiology (C.T., Y.B., Q.D., M.P., D.R.), Division of Clinical Research and Innovation (M.D.), and Intensive Care Unit, Department of Nephrology (M.S.), University Hospital Amiens, France; INSERM U-1088, Jules Verne University of Picardie, Amiens, France (C.T., S.M., M.S., D.R.); Groupement des Hôpitaux de l'Institut Catholique de Lille/Faculté libre de médecine, Université Lille Nord de France (S.M.); Department of Cardiology, Centre Hospitalier Universitaire de Lille, F-59000, France (N.D.) and Department of Cardiology, Cardiovascular Division, AP-HP, Bichat Hospital, Paris, France (D.M.-Z.).
authors.forename: Marcel
authors.initials: M
authors.lastname: Peltier
authors.affiliation: From the Department of Cardiology (C.T., Y.B., Q.D., M.P., D.R.), Division of Clinical Research and Innovation (M.D.), and Intensive Care Unit, Department of Nephrology (M.S.), University Hospital Amiens, France; INSERM U-1088, Jules Verne University of Picardie, Amiens, France (C.T., S.M., M.S., D.R.); Groupement des Hôpitaux de l'Institut Catholique de Lille/Faculté libre de médecine, Université Lille Nord de France (S.M.); Department of Cardiology, Centre Hospitalier Universitaire de Lille, F-59000, France (N.D.) and Department of Cardiology, Cardiovascular Division, AP-HP, Bichat Hospital, Paris, France (D.M.-Z.).
authors.forename: Momar
authors.initials: M
authors.lastname: Diouf
authors.affiliation: From the Department of Cardiology (C.T., Y.B., Q.D., M.P., D.R.), Division of Clinical Research and Innovation (M.D.), and Intensive Care Unit, Department of Nephrology (M.S.), University Hospital Amiens, France; INSERM U-1088, Jules Verne University of Picardie, Amiens, France (C.T., S.M., M.S., D.R.); Groupement des Hôpitaux de l'Institut Catholique de Lille/Faculté libre de médecine, Université Lille Nord de France (S.M.); Department of Cardiology, Centre Hospitalier Universitaire de Lille, F-59000, France (N.D.) and Department of Cardiology, Cardiovascular Division, AP-HP, Bichat Hospital, Paris, France (D.M.-Z.).
authors.forename: Michel
authors.initials: M
authors.lastname: Slama
authors.affiliation: From the Department of Cardiology (C.T., Y.B., Q.D., M.P., D.R.), Division of Clinical Research and Innovation (M.D.), and Intensive Care Unit, Department of Nephrology (M.S.), University Hospital Amiens, France; INSERM U-1088, Jules Verne University of Picardie, Amiens, France (C.T., S.M., M.S., D.R.); Groupement des Hôpitaux de l'Institut Catholique de Lille/Faculté libre de médecine, Université Lille Nord de France (S.M.); Department of Cardiology, Centre Hospitalier Universitaire de Lille, F-59000, France (N.D.) and Department of Cardiology, Cardiovascular Division, AP-HP, Bichat Hospital, Paris, France (D.M.-Z.).
authors.forename: David
authors.initials: D
authors.lastname: Messika-Zeitoun
authors.affiliation: From the Department of Cardiology (C.T., Y.B., Q.D., M.P., D.R.), Division of Clinical Research and Innovation (M.D.), and Intensive Care Unit, Department of Nephrology (M.S.), University Hospital Amiens, France; INSERM U-1088, Jules Verne University of Picardie, Amiens, France (C.T., S.M., M.S., D.R.); Groupement des Hôpitaux de l'Institut Catholique de Lille/Faculté libre de médecine, Université Lille Nord de France (S.M.); Department of Cardiology, Centre Hospitalier Universitaire de Lille, F-59000, France (N.D.) and Department of Cardiology, Cardiovascular Division, AP-HP, Bichat Hospital, Paris, France (D.M.-Z.).
authors.forename: Dan
authors.initials: D
authors.lastname: Rusinaru
mesh_terms: 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; D058070:Asymptomatic Diseases; D001827:Body Height; D015992:Body Mass Index; D001830:Body Surface Area; D001835:Body Weight; D018572:Disease-Free Survival; D015150:Echocardiography, Doppler; D005260:Female; D005602:France; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013318:Stroke Volume; D013997:Time Factors; D016896:Treatment Outcome; D016277:Ventricular Function, Left
keywords: aortic valve; aortic valve stenosis; asymptomatic conditions; echocardiography; prognosis