Right-heart remodelling in patients with moderate aortic stenosis and its prognostic implications
I Rodrigues, A Goncalves, F Nunes, F Sousa, L Moura, M Almeida, A Lobo, I Neves, M Leite, R Teixeira, R Fontes-CarvalhoAbstract
Background
In patients with severe aortic stenosis (AS), right ventricular (RV) dysfunction can reflect advanced stages of cardiac remodelling and has been associated with poor outcomes. The prevalence and prognostic relevance of right-heart involvement in earlier stages of AS remain insufficiently characterized.
Purpose
To assess the prevalence of elevated systolic pulmonary artery pressure (sPAP) and RV dysfunction, and their association with all-cause mortality, in patients with moderate AS.
Methods
We retrospectively included all patients diagnosed with moderate AS between 2015 and 2022. Patients with more than moderate aortic regurgitation or bicuspid aortic valve were excluded. RV dysfunction was defined as TAPSE <18 mm, and elevated sPAP as ≥35 mmHg. Patients were stratified into three groups: (1) normal sPAP and preserved TAPSE; (2) elevated sPAP with preserved TAPSE; and (3) elevated sPAP with reduced TAPSE. Survival was analysed using Kaplan–Meier estimates and Cox proportional hazards models.
Results
A total of 423 patients were included (48% female; mean age 76±8.4 years), with a high prevalence of cardiovascular risk factors (hypertension 89%, dyslipidaemia 76%, diabetes mellitus 37%, smoking 18%, obesity 32%). 28% had previously known coronary artery disease and 30% had atrial fibrillation. Transthoracic echocardiography demonstrated left atrial (LA) enlargement (mean indexed LA volume 46±17.5 mL/m²), preserved left ventricular ejection fraction (59±6%), mildly impaired global longitudinal strain (−16.6±5.8%), and parameters consistent with moderate AS (median aortic valve area 1.2 [1.1–1.3] cm²; peak velocity 3.4 [3.2–3.6] m/s; mean gradient 27 [23–31] mmHg). Elevated PSAP was present in 47.4% of patients, while RV dysfunction was observed in 7.6%. Overall, 51.6% of patients showed no evidence of right-heart involvement (group 1), 27.0% presented with isolated elevated sPAP (group 2), and 7.2% exhibited concomitant elevated sPAP and reduced TAPSE (group 3). Kaplan–Meier analysis showed a significant stepwise reduction in survival across right-heart phenotypes with worse survival observed in patients with elevated sPAP and the poorest outcomes in those with concomitant sPAP elevation and RV dysfunction (log-rank p=0.005). In Cox proportional hazards models, isolated sPAP elevation was independently associated with increased mortality (HR 1.60, 95% CI 1.10–2.30; p=0.007), and the coexistence of elevated sPAP and RV dysfunction identified a particularly high-risk subgroup (HR 2.22, 95% CI 1.20–4.10; p=0.012) (Figure 1).
Conclusions
In patients with moderate AS, right-heart involvement is common and associated with a markedly worse prognosis. Elevated sPAP, particularly when accompanied by RV dysfunction, may represent an important marker for risk stratification in this population.Cox regression analysisFor image description, please refer to the figure legend and surrounding text.