Combined Cardiac Damage Staging by Echocardiography and Cardiac Catheterization in Patients with Clinically Significant Aortic Stenosis

BACKGROUND:Cardiac damage (CD) staging enhances risk stratification in patients with clinically significant aortic stenosis (AS). We aimed to assess the prognostic value and reclassification rate of right heart catheterization (RHC) compared to echocardiography (TTE) in characterizing CD-staging at 3-year follow-up in patients with clinically significant AS; to identify patients that would benefit from RHC for prognostic stratification; to test the prognostic value of "combined" CD-staging. METHODS:Observational cohort study of 432 AS patients undergoing TTE and RHC, divided into moderate/asymptomatic severe (m/asAS) and symptomatic severe AS (ssAS). Kaplan-Meier curves were used to compare survival. The accuracy in prognostic stratification was tested by AUC analysis and Delong's test. RESULTS:In both cohorts, TTE- and RHC-derived staging systems had prognostic value, although the agreement between them appeared moderate. A higher proportion of patients were assigned to Stage 2 by TTE, compared to RHC. Patients in TTE-derived Stage 2 had a high reclassification rate, with 40-50% presenting with right chambers involvement (stages 3-4) at RHC. "Discordant" cases were significantly older, with higher prevalence of atrial fibrillation, markedly elevated N-terminal pro-brain natriuretic peptide, higher left atrial volume indexed, E/e' and systolic pulmonary artery pressure versus "concordant" cases (p<0.05). The "combined" CD-staging, integrating TTE and RHC, was more accurate in predicting mortality than TTE-derived system (p<0.05). CONCLUSION:In patients with m/asAS and ssAS, the "combined" CD-staging, derived from TTE and RHC, was more accurate in predicting mortality than TTE. In a subset of AS patients, the integration of RHC may significantly improve prognostic stratification.