Dobutamine echocardiography impact on managing low-gradient aortic stenosis and solving the issue with inconclusive studies
Notice bibliographique
Résumé
Abstract Background Guidelines advocate the use of dobutamine echocardiography (DSE) in low-gradient aortic stenosis (LGAS: AVA<1cm² with AVMG<40mmHg) with reduced left ventricular ejection fraction (LVEF <50%) for determining AS severity and deciding on subsequent patient management. However, a significant proportion of patients have inconclusive DSE (indeterminate AS). Purpose We aimed to assess the impact of DSE on the management of patients with LGAS and reduced LVEF as well as the application of transaortic flow-based criteria for severe AS to improve the diagnostic yield of DSE. Finally, we aimed to review the impact of aortic valve intervention in those with indeterminate AS. Methods Accordingly, a retrospective analysis of 287 patients with LGAS and reduced LVEF (<50%) who underwent DSE was performed. We used the conventional criteria for classification of AS severity following DSE: severe AS when AVA <1cm² with AVMG ≥40mmHg, moderate AS when AVA ≥1cm², and indeterminate AS when AVA <1cm² and AVMG <40mmHg during stress. Furthermore, we assessed the proposed new criteria for AS classification: AVA <1cm² at normalised FR ≥210ml/s and projected AVA <1cm² at FR of 250ml/s. We also assessed the impact of afterload on the different AS groups by means of valvular resistance (valve disease related afterload) and arterial impedance (vascular disease related afterload). Results Following DSE 84 (29%) patients had severe AS, 81 (28%) moderate AS, and 122 (43%) indeterminate AS. Over the median follow-up of 12.0 (IQR= 5-33) months more patients with severe AS (73%) underwent aortic valve intervention compared with moderate (40%) and indeterminate AS (44%) (p< 0.001). In terms of afterload, the valvular resistance was significantly higher in patients with severe AS compared to indeterminate AS (p<0.001), but arterial impedance was higher in indeterminate AS amongst all 3 groups (p=0.02). Use of the proposed combined criteria for severe AS (AVA <1cm² at FR ≥210ml/s or projected AVA) in the indeterminate AS group improved the proportion of diagnostic tests from 57% to 90%, increased detection of severe AS from 29% to 61%, and reduced indeterminate AS to 9%. Aortic valve intervention was beneficial in the reclassified severe AS patients (HR 0.50, 95%CI 0.27-0.92, p=0.03) (Fig.1A), but not in the remaining indeterminate AS patients (HR 0.77, 95%CI 0.22-2.75, p=0.69) (Fig.1B). The benefit of aortic valve intervention was larger in the conventionally diagnosed severe AS patients compared to the reclassified severe AS patients (HR 2.88, 95%CI 1.34-6.21, p=0.007) (Fig.1C). Conclusions Clinicians managed LGAS patients according to DSE-determined AS severity. Application of the proposed combined criteria for severe AS reduced the number of non-diagnostic DSE and increased the detection of severe AS. In the reclassified severe AS patients aortic valve intervention can be beneficial, but not in those who remained indeterminate AS. Figure 1
Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.
Comment cette classification a été obtenuedéplier
Prédiction distillée sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Apprise à partir de 10 348 étiquettes directes de Codex et de 10 348 étiquettes directes de Gemma. Le mode candidate est l'union des têtes enseignantes seuillées; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont ni des étiquettes humaines ni des étiquettes directes de modèles de pointe.
Scores Codex et Gemma par catégorie
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,001 | 0,000 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,001 | 0,004 |
| Bibliométrie | 0,000 | 0,001 |
| Études des sciences et des technologies | 0,001 | 0,000 |
| Communication savante | 0,000 | 0,000 |
| Science ouverte | 0,000 | 0,000 |
| Intégrité de la recherche | 0,000 | 0,000 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,000 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule tête enseignante, pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».