Proof Of Concept Study On The Utility Of Integrated Transthoracic And Transesophageal Echocardiography Aortic Stenosis Assessment

Abstract Background Integrated echo method (IEM) combining transthoracic and transesophageal echocardiography (TTE/TEE) data can provide accurate aortic stenosis (AS) assessment. Our objectives were to evaluate the impact of IEM classification on mortality in AS patients. Methods Between 2016–2017, 63 out of 81 consecutive patients with at least moderate AS underwent comprehensive sequential TTE and TEE. AS types were determined by TTE and IEM (utilizing TEE planimetry of left ventricular outflow tract and highest Doppler spectral signals from both TTE and TEE). Based on conservative vs actionable implication, AS types were dichotomized into Group A, comprising moderate and Normal-Flow Low-Gradient (NFLG), and Group B, comprising High-Gradient (HG), Low ejection fraction Low-Flow Low-Gradient (Low EF LFLG), and Paradoxical Low-Flow Low-Gradient (PLFLG) AS. Survival under medical therapy was determined. Results Dichotomous classification was discordant in 15.9% of the patients with the two methods, with a relative risk of 1.55 of A to B Group re-classification with IEM (p<0.001). The optimal cut-off value of TTE-determined AVA for AS classification was 0.82 cm2 (75% sensitivity and 87% specificity) vs an IEM-determined optimal AVA cut-off value of 0.92 cm2 (84.4% sensitivity and 76% specificity). During a median time of 9 months (quartiles 2.4–22 months) of follow-up under medical treatment, Group B patients had a worse survival under medical therapy than Group A patients, with additional independent prognostic value for Group A/B dichotomization by IEM in Group A (non-actionable) TTE-defined patients after multivariable adjustment (hazard ratio 5.3, confidence interval 1.39–20.3, p value=0.015). Conclusions IEM in patients with ambiguous AS severity can improve detection of patients who may benefit from early invasive therapy. Graphical Abstract Funding Acknowledgement Type of funding source: None