Pressures at an All-Time High | Circulation
How Fast Does Aortic Stenosis Progress?
Someone living with aortic stenosis that progresses quickly often has a worse outlook. But you can take steps to catch this heart issue early and work with your healthcare team to treat it.
Your aortic valve is one of four valves in your heart. It's like the exit valve of your heart, where oxygen-rich blood is pumped out of the heart to the rest of your body. As the main portal for blood to flow to all your tissues, it's important that your aortic valve remains clear and open.
Over time — or with certain structural problems that can be present at birth — the aortic valve can become narrowed with calcium deposits, inflammation, and stiffening that limits blood flow. This condition — aortic stenosis — is one of the most common reasons for heart valve surgery.
This article explores how quickly aortic stenosis can develop and progress, what you might feel as this is happening, and what can be done to correct this problem.
How quickly aortic stenosis develops and progresses can vary from person to person based on age, the underlying reason for the stenosis, and other health problems that may exist.
Calcification or hardening of the aortic valve over time is the leading cause of aortic stenosis.
There's no confirmed formula to determine why some aortic stenosis diagnoses progress quickly, while others happen more slowly. But research indicates that rapid progression usually leads to more severe disease and higher rates of complications or death.
Aortic stenosis is staged based on how much blood flow to the aorta is limited and what other cardiac problems have developed from decreased blood flow.
The American College of Cardiology uses letters to describe Stages A–D, while the European Heart Journal uses numbers to classify Stages 0–4, and the descriptions are slightly different.
Staging of aortic stenosis is usually done with an echocardiogram. Generally, people who have higher stages of aortic stenosis are older, male, and have other contributing health problems.
There are several health problems that can exist alongside aortic stenosis and contribute to its development and how fast it progresses.
Older people and those in already frail health often progress through this disease more quickly and with more extensive cardiac damage.
People who have aortic stenosis that's progressed to severe aortic stenosis may also have:
Symptoms that can appear with aortic stenosis are related to how limited blood flow becomes. For many people, symptoms don't appear until blood flow is significantly restricted through the aortic valve and other heart or cardiac damage develops.
When symptoms do appear, they can include things like:
As aortic stenosis progresses to later stages, symptoms become more severe and may evolve into other serious conditions like heart failure or pulmonary hypertension.
Learn more about the symptoms of heart failure and symptoms of pulmonary hypertension.
People with severe symptoms and advanced stages of aortic stenosis have the highest risk of sudden death. Sudden death can also occur in people without symptoms of aortic stenosis, but this is less common.
Although rates of progression to higher stages varies, people whose condition progresses more quickly to more serious stages of aortic stenosis over a shorter period of time usually have worse outcomes and higher rates of dying.
Stages 4 and 5 have the highest rates of death and other complications. But according to experts, research suggests that even stage 1 of aortic stenosis has a 9.2% mortality rate 1 year after diagnosis.
Early diagnosis and treatment with valve replacement surgery can help prevent stenosis leading to additional cardiac damage. Currently, there are limited other treatment measures that can help prevent, slow, or stop aortic stenosis progression.
Aortic stenosis can develop without symptoms, but over time, the stiffening and narrowing of the aortic valve decreases blood flow from the heart out to the rest of the body. This can lead to severe symptoms that reduce your daily ability to function, which can cause complications like heart failure. Aortic stenosis progression can even lead to death.
Early recognition, confirmed diagnosis, and treatment with valve replacement and medications can help improve blood flow through your aortic valve and prevent further damage to the heart.
Permanent Pacemaker Implantation Frequently Follows Tricuspid Valve Surgery, Study Finds
Among Medicare beneficiaries, implantation was especially frequent for female patients and those undergoing tricuspid valve replacement with or without concomitant left-sided heart surgeries.
Implantation of a permanent pacemaker (PPM) often follows tricuspid valve surgery (TVS), particularly in female patients and those undergoing TV replacement with or without concomitant left-sided heart surgeries, according to a study published in the Journal of the American Heart Association.
While mortality rates remained unaffected, the procedure was linked to elevated rates of heart failure (HF) rehospitalization and worsening tricuspid regurgitation (TR) among Medicare beneficiaries.
The final study cohort included 13,294 Medicare beneficiaries who underwent any form of TVS between 2013 and 2020, with 2518 (18.9%) requiring postsurgical PPM implantation and 10,776 (81.1%) not requiring a PPM. Patients who underwent TVS for endocarditis were excluded.
Risk factors for PPM implantation included:
Interestingly, a smaller retrospective study conducted at 2 academic medical centers over a 5-year period did not find significant differences in sex between patients requiring a PPM and those who did not. However, the current study, with a significantly larger cohort size—13,294 vs 237 patients—provided novel insights into these associations.
TV replacement posed a significantly higher risk of PPM implantation compared with TV repair (RR, 3.20; 95% CI, 2.16-4.75; P < .0001). However, after a median follow-up of 3.1 years, there was no difference in mortality between patients who received PPM and those who did not (HR, 1.02; 95% CI, 0.93-1.12; P = .7). Additionally, while PPM placement was not associated with a higher risk of endocarditis, it was linked to an increased risk of HF readmission (HR, 1.28; 95% CI, 1.14-1.43; P < .001).
PacemakerImage credit: Birgit Reitz-Hofmann – stock.Adobe.Com
"The increased risk of HF readmission could be linked to the increased rates of TR, which is commonly described after PPM implantation with a frequency ranging from 7% to 45%, according to different studies," the authors noted.
The frequency of PPM implantation following isolated TVS appeared to surpass that observed after isolated left-sided heart surgeries. Specifically, 27.3% and 12.6% of patients undergoing isolated TV replacement or repair, respectively, required a PPM.
Upon further literature review, the authors found lower rates in patients undergoing isolated mitral valve surgery (0.8%), coronary artery bypass grafting (4%), surgical aortic valve replacement (2.7%), or transcatheter aortic valve replacement (7.75%). These findings align with previous studies, including a 10-year analysis of TVS trends that reported a 26% incidence of PPM implantation, as well as a recent randomized controlled trial on mitral valve surgery where surgery plus tricuspid annuloplasty resulted in a significantly higher PPM implantation rate compared with surgery alone (14.1% vs 2.5%).
"The reason behind the high risk of PPM implantation as a result of heart block following TVS is primarily anatomic," the authors said. "The atrioventricular node resides in the muscular atrioventricular septum at the apex of the triangle of Koch, which borders the TV. Thus, the former is highly susceptible to injuries during intervention, increasing the risk of postoperative high-degree atrioventricular block, the most common indication of pacing following TVS."
It's important to note that the necessity for PPM implantation varies across different types of TVS. While comparative data are scarce, TV repair is generally favored over TV replacement, particularly when repair is feasible, due to its simpler and faster nature and associated reductions in in-hospital and operative mortalities. Despite similar long-term survival rates between repair and replacement, isolated TV replacement was significantly associated with a higher risk of postprocedural PPM implantation compared to repair (RR, 2.2; 95% CI, 1.87-2.58; P < .0001), likely due to the close anatomical relationship between the tricuspid apparatus and the conduction system. Techniques during TV replacement, such as careful suture placement and monitoring for rhythm changes, can help mitigate postoperative conduction disturbances.
The study's limitations include potential errors in coding due to its administrative database source and the absence of echocardiographic data, which could affect outcome interpretation. Additionally, as the cohort was restricted to Medicare patients, the generalizability of the findings to the broader population may be limited, despite extensive matching on confounders.
ReferenceKassab J, Harb SC, Desai MY, et al. Incidence, risk factors, and outcomes associated with permanent pacemaker implantation following tricuspid valve surgery. J Am Heart Assoc. Published online January 31, 2024. Doi:10.1161/JAHA.123.032760
FDA Advisors Nearly All Aboard The TriClip Train For Tricuspid Regurgitation
FDA advisors were nearly unanimous in backing the TriClip G4 transcatheter edge-to-edge repair (TEER) device as a treatment for severe tricuspid regurgitation (TR).
During an advisory committee meeting on Tuesday, the FDA's Circulatory System Devices Panel voted 13-1 that the benefits of the TriClip outweigh the risks when used for intermediate-or-higher-risk patients with severe TR who have symptoms despite optimal medical therapy.
Evidence that the TriClip reduced TR without excess safety events and significantly improved the Kansas City Cardiomyopathy Questionnaire (KCCQ) overall score, a patient-reported quality-of-life metric, was enough for the majority of Tuesday's panelists to vote yes to both the device's effectiveness (12-2) and safety (14-0).
"The safety data speaks for itself. The device performs very well," said surgeon David Yuh, MD, of Stamford Hospital in Connecticut, who called TriClip a "significant advance" for the treatment of right heart failure.
"If we can help symptoms at a low cost in terms of risk, it makes a lot of sense," said James Blankenship, MD, an interventional cardiologist at the University of New Mexico in Albuquerque. He noted that the safety profile of the TriClip TEER seems better than many established procedures, including hip replacement.
Committee members generally agreed while acknowledging that the TRILUMINATE trial, the basis of TriClip's premarket application, technically met the superiority composite endpoint without being able to prove that the device helps hard outcomes any better than medical therapy alone.
In that open-label pivotal trial, TriClip recipients showed improved health status for patients on Bayesian analysis (win ratio 1.44, 95% CI 1.03-2.08). The only individual component of this primary endpoint to significantly favor the device was the KCCQ (≥15-point improvement achieved by 50% vs 26% of patients) -- with no reduction in mortality or heart failure hospitalization per se.
"In terms of efficacy, what the patient is experiencing, I do put a lot of faith in the KCCQ data even though [there are concerns about] the placebo effect," Yuh said. "It's still the reality to the patient, and to discount that does a disservice to the patient."
As for safety in TRILUMINATE, there were numerically more deaths, tricuspid valve interventions, and bleeding events associated with the TriClip intervention. Being that the small differences did not reach statistical significance, however, no one on Tuesday's panel expressed concerns about major adverse events occurring in patients.
FDA advisory committee members did take issue with the finding that TriClip's benefits in the trial did not extend to participating sites enrolling fewer than 10 patients, suggesting a steep learning curve precluding broad adoption for operators.
Notably, Abbott had taken the design for the TriClip from the MitraClip, now considered a mature technology for treating primary and secondary mitral regurgitation. Curiously, data suggest that more experience with the MitraClip did not appear to correlate with better TriClip outcomes in lower-enrolling centers.
TR occurs when the tricuspid valve leaflets do not close completely during systole, causing blood to regurgitate from the right ventricle into the right atrium. Affected patients have few treatment options, and surgery is often high-risk due to a typically older, sicker patient profile.
Abbott is proposing that TriClip be indicated for improvement of "health status" in patients with severe TR that is symptomatic despite optimal medical therapy and who are at intermediate or greater risk for surgery and deemed appropriate TEER candidates by a heart team.
"I think it's important to consider the alternatives for these patients, and the alternatives are limited," said Bradley Bart, MD, of the University of Minnesota and Minneapolis VA Medical Center.
That may change in the near future as many transcatheter therapies are currently being developed for TR.
In fact, the FDA just approved the Evoque tricuspid valve replacement system by Edwards Lifesciences, while that company's Pascal repair system has its pivotal CLASP II TR trial scheduled for completion at the end of this year.
Abbott said it has a continued access protocol that will follow several hundred TriClip patients for 5 years after the procedure. The device maker is also proposing postmarket surveillance of the TriClip device through the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry should the device be FDA approved.
Panelist Marc Katz, MD, MPH, of the Medical University of South Carolina in Charleston, said he had concerns about indication creep in the real world resulting in sicker, non-TRILUMINATE-like patients getting the device. "That's not going to help results overall, especially as less experienced teams get involved."
He said he voted no to TriClip's efficacy but ultimately "caved" and voted yes for the benefit-risk question based on his personal experience on putting MitraClips in the tricuspid position. "There is a role for it in a limited population. It's going to have to find its niche between valves and leaflet modification."
The sole "no" vote for benefit-risk came from Paul Hauptman, MD, of the University of Nevada in Reno, who expressed the "need to pull back on unbridled enthusiasm" for the TriClip. He cautioned that important questions remain, including a better definition of which patients are likely to benefit.
He encouraged the FDA to look critically at data from the continued access protocol at 1 year. He also suggested more work to evaluate post-implant deployment of defibrillator leads and pacemaker leads in TriClip recipients and what happens a few years later when patients need their leads revised.
The FDA is not required to follow the advice of its advisory committees, but it often does.
Nicole Lou is a reporter for MedPage Today, where she covers cardiology news and other developments in medicine. Follow
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