Brief Title
Randomized Study for the Optimal Treatment of Symptomatic Patients With Low Gradient Severe Aortic Valve Stenosis and Preserved Left Ventricular Ejection Fraction
Official Title
Randomized Study for the Optimal Treatment of Symptomatic Patients With Low Gradient Severe Aortic Valve Stenosis and Preserved Left Ventricular Ejection Fraction
Brief Summary
According to current European Recommendations on valvular heart disease (VHD), "classical" severe aortic stenosis (AS) is defined by an aortic valve area (AVA) ≤1 cm2 and indexed AVA ≤0.6 cm2/m2, a mean aortic pressure gradient (MAG) >40 mmHg, and a maximal aortic velocity >4 m/sec. Aortic valve replacement (AVR) is recommended (class I indication) in patients with "classical" severe AS who have any symptoms related to aortic valve disease. In 2007, Hachicha et al. described a particular pattern of severe AS, characterized by an AVA ≤0.6 cm2/m2, low mean pressure aortic gradient (MAG <40 mmHg), despite the presence of a preserved left ventricular ejection fraction (LVEF ≥50%). This pattern of AS is encountered in nearly 15-25 % of patients who have severe AS. Typically, these patients are elderly subjects, with several comorbidities, a small left ventricular (LV) cavity with pronounced LV concentric remodeling and a restrictive physiology, leading to a decrease in LV stroke volume despite a preserved LVEF. The diagnosis and management of patients with low gradient severe AS and preserved LVEF are often challenging because: 1. the presence of a "true" severe aortic stenosis should be carefully confirmed by a multi-modality imaging approach; 2. the best therapeutic management (AVR versus conservative strategy) of symptomatic patients with low gradient severe AS and preserved LVEF is not clearly established. In very recently updated European guidelines on the management of VHD, symptomatic patients with low gradient and low flow severe AS and preserved LVEF have only a class IIa-level C indication for AVR. No specific indications are given for the management of symptomatic patients with low gradient and normal flow severe AS. This lack of indications is clearly attributed to a gap in knowledge which requires further investigations to be filled up.
Study Type
Interventional
Primary Outcome
time from randomization to first occurrence of any of the components of the composite outcome (adjudicated): all-cause mortality or cardiovascular related hospitalization
Secondary Outcome
rate of all-cause mortality
Condition
Aortic Valve Stenosis
Intervention
aortic valve replacement
Study Arms / Comparison Groups
aortic valve replacement
Description:
Publications
* Includes publications given by the data provider as well as publications identified by National Clinical Trials Identifier (NCT ID) in Medline.
Recruitment Information
Recruitment Status
Procedure
Estimated Enrollment
360
Start Date
March 19, 2019
Completion Date
March 2025
Primary Completion Date
March 19, 2024
Eligibility Criteria
Inclusion Criteria: 1. Age >18 years 2. Symptomatic and severe AS defined by an effective AVA ≤1 cm² and indexed AVA ≤0.6 cm2/m2 3. LVEF ≥50% 4. MAG <40 mm Hg (measure confirmed by the multi-window continuous-wave Doppler interrogation and use of Pedoff probe) 5. Confirmation of the presence of severe AS at DSE and MDCT aortic calcium score 6. Feasibility of AVR by surgery or TAVR according to the "heart team" 7. Signature of an informed consent Exclusion Criteria: 1. Uncontrolled atrial of ventricular arrhythmias 2. Patient having a life expectancy <1 year, independently from their aortic pathology 3. Coronary artery disease necessitating a percutaneous or surgical revascularisation 4. Presence of a concomitant valve disease needing surgical treatment 5. Patient who are included in another research protocol 6. Protected person (adults legally protected (under judicial protection, guardianship or supervision), person deprived of their liberty, pregnant woman, lactating woman and minor)
Gender
All
Ages
18 Years - N/A
Accepts Healthy Volunteers
No
Contacts
Elena EG Galli, MD, 02 99 28 25 55, [email protected]
Location Countries
Belgium
Location Countries
Belgium
Administrative Informations
NCT ID
NCT03667365
Organization ID
35RC17_8843_ROTAS
Secondary IDs
2018-A02100-55
Responsible Party
Sponsor
Study Sponsor
Rennes University Hospital
Study Sponsor
Elena EG Galli, MD, Principal Investigator, CHU Rennes
Verification Date
November 2019