Predictors of survival after aortic valve replacement in patients with low-flow and high-gradient aortic stenosis

Abstract Aims The ESC/EACTS guidelines propose criteria that determine the likelihood of true-severe aortic stenosis (AS). We aimed to investigate the impact of the guideline-based criteria of the likelihood of true-severe AS in patients with low-flow low-gradient (LFLG) AS with preserved ejection fraction (pEF) on outcomes following transcatheter aortic valve replacement (TAVR). Methods and results In a prospective TAVR registry, LFLG-AS patients with pEF were retrospectively categorized into high (criteria ≥6) and intermediate (criteria <6) likelihood of true-severe AS. Haemodynamic, functional, and clinical outcomes were compared with high-gradient AS patients with pEF. Among 632 eligible patients, 202 fulfilled diagnostic criteria for LFLG-AS. Significant haemodynamic improvement after TAVR was observed in LFLG-AS patients, irrespective of the likelihood. Although >70% of LFLG-AS patients had functional improvement, impaired functional status [New York Heart Association (NYHA III/IV)] persisted more frequently at 1 year in LFLG-AS than in high-gradient AS patients (7.8%), irrespective of the likelihood (high: 17.4%, P = 0.006; intermediate: 21.1%, P < 0.001). All-cause death at 1 year occurred in 6.6% of high-gradient AS patients, 10.9% of LFLG-AS patients with high likelihood [hazard ratio (HR)adj 1.43, 95% confidence interval (CI) 0.68–3.02], and in 7.2% of those with intermediate likelihood (HRadj 0.92, 95% CI 0.39–2.18). Among the criteria, only the absence of aortic valve area ≤0.8 cm2 emerged as an independent predictor of treatment futility, a combined endpoint of all-cause death or NYHA III/IV at 1 year (OR 2.70, 95% CI 1.14–6.25). Conclusion Patients with LFLG-AS with pEF had comparable survival but worse functional status at 1 year than high-gradient AS with pEF, irrespective of the likelihood of true-severe AS. Clinical Trial Registration https://www.clinicaltrials.gov. NCT01368250.

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Low-Flow, Low-Gradient Severe Aortic Stenosis: Cardiac Computed Tomography Findings and Clinical Outcomes After Aortic Valve Replacement

10.21203/rs.3.rs-1151439/v1 ◽

2021 ◽

Author(s):

Se Jin Choi ◽

Yura Ahn ◽

Hyun Jung Koo ◽

Dae-Hee Kim ◽

Soyeon Lim ◽

...

Keyword(s):

Atrial Fibrillation ◽

Aortic Valve ◽

Aortic Stenosis ◽

Aortic Valve Replacement ◽

Old Age ◽

Valve Replacement ◽

Left Ventricular ◽

Aortic Annulus ◽

Low Flow ◽

High Gradient

Abstract Aortic valve calcium scoring by cardiac computed tomographic (CT) has been recommended as an alternative to classify the AS severity, but it is unclear that whether CT findings can predict and have prognostic implication in low-flow, low-gradient aortic stenosis (LF-LG AS), which has fewer benefit from surgery among the AS subtypes. In this study, we examined the clinical and cardiac CT findings of LF-LG AS patients and evaluated factors affecting outcomes after surgical aortic valve replacement (AVR). This study included 511 (66.9±8.8 years, 55% men) consecutive patients with severe AS who underwent surgical AVR. Aortic valve area (AVA) was obtained by echocardiography (AVAecho) and by CT (AVACT) using each modalities measurement of the left ventricular outflow tract. Patients with AS were classified as 1) high-gradient severe (n=438), 2) classic LF-LG (n=18), and 3) paradoxical LF-LG (n=55) based on echocardiography. Classic LF-LG AS patients had higher end-systolic and end-diastolic volume indices, lower left ventricular ejection fraction, larger AVAecho and AVACT, and larger aortic annulus compared to high-gradient severe AS (P<0.05, for all). In classic LF-LG AS group, 27.8% of patients presented AVACT≥1.2 cm2. After multivariable adjustment, old age (hazard ratio [HR], 1.04, P=0.049), high B-type natriuretic peptide (BNP) (HR, 1.005; P<0.001), preoperative atrial fibrillation (HR, 2.75; P=0.003), classic LF-LG AS (HR, 5.53, P=0.004), and small aortic annulus (HR, 0.57; P=0.002) were independently associated with major adverse cardiac and cerebrovascular events (MACCE). The classic LF-LG AS group presented larger AVACT and aortic annulus than those in high-gradient severe AS group and one third of them had AVACT ≥1.2 cm2. Old age, high BNP, atrial fibrillation, classic LF-LG AS, and small aortic annulus were associated with MACCE in severe AS patients after surgical AVR.

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prognostic evaluation of patients benefiting from a trans aortic valve replacement according to the type of aortic stenosis

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jeaa356.057 ◽

2021 ◽

Vol 22 (Supplement_1) ◽

Author(s):

M Lacout ◽

C David ◽

A Bernard ◽

C Saint Etienne ◽

JM Clerc ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Left Ventricular ◽

Low Flow ◽

Left Ventricular Ejection ◽

Normal Flow ◽

High Gradient ◽

Normal Lvef

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Aortic Stenosis (AS) is a common condition in patients over 75 years. Latest ESC recommendations differentiate 4 types of AS according to: Indexed Stroke Volume (SVi), mean gradient and left ventricular ejection fraction (LVEF). The aim of our study is to evaluate prognosis of patients who have had a transcatheter aortic valve replacement (TAVR), in terms of mortality, according to the 4 types of AS. Methods This study compares prognosis of 620 patients who had TAVR between January 1, 2015 and December 31, 2018. Patients were classified into 4 groups according to AS type: high gradient; low gradient, low flow, low LVEF; low gradient, low flow, normal LVEF; low gradient, normal flow. Results 69 patients (11.1%) died within 12 months of the procedure: 49 in the high gradient group (9.4%); 13 in the low gradient, low flow, low LVEF group (47.1%); 1 in the low gradient, low flow, normal LVEF group (5%); 6 in the low gradient, normal flow, normal LVEF group (18.2%). All-cause mortality at one year follow-up is higher in low-gradient, low-flow, altered LVEF group (p = 0.0004) than in other groups. Patients in this group were significantly more often admitted for heart failure than patients in high-gradient group (p = 0.009). Conclusion A complete echocardiography evaluation is needed to evaluate AS, its severity and type. Patients in the low gradient, low flow, low LVEF group have an independent risk of mortality at 12 months higher than other groups and are more hospitalized than patients in the high gradient group.

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Abstract 12660: Impact of Aortic Valve Replacement versus Medical Management on Survival of Low Flow Low Gradient Severe Aortic Stenosis With Normal Ejection Fraction

Circulation ◽

10.1161/circ.132.suppl_3.12660 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Zaher Fanari ◽

Dimitrios Barmpouletos ◽

Vivek K Reddy ◽

Sumaya Hammami ◽

Zugui Zhang ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Severe Aortic Stenosis ◽

Low Flow ◽

Rank Test ◽

Normal Ejection Fraction ◽

Normal Flow ◽

Log Rank Test

Background: The impact of aortic valve replacement (AVR) versus medical management (MM) in patients with paradoxical low flow is unclear. The objective of this study was to compare outcomes of AVR versus MM in patients with severe aortic stenosis and normal ejection fraction and different transaortic flow and gradient. Methods: We identified consecutive patients presenting to our echo lab with an aortic valve area (AVA) < 1.0cm 2 and EF≥ 50%. We stratify patients depending on gradient (≥ 40 vs. < 40 mmHg) and stroke volume index (SVI < 35 vs. ≥35 ml/m 2 ). 4 groups were identified (, normal flow, high gradient [NF/HG]; normal flow, low gradient [NF/LG]; low flow, high gradient [LF/HG] and low flow, low gradient [LF/LG]. These 4 groups were also stratified depending on management (AVR vs. MM). All patients were retrospectively followed for the occurrence of death. Results: A total of 954 patients were included in analysis. Mean follow up was 2.45 ± 1.9 years. The mean age was 75.4 ± 5.6 years. Comparing all 4 AS subgroups, the mortality was higher in LF/HG followed by LF/LG, NF/HG and NF/LG (LF/HG 37.1% vs. LF/LG 33.9% vs. NF/HG 30.3%vs. NF/LG 20.2%; Log Rank Test, P=0.003). Patients who underwent medical therapy have a higher mortality than the overall cohort in all subgroups (LF/HG 44.3% vs. NF/HG 36.6% vs. LF/LG 33.7% vs. NF/LG 21.2%; Log Rank Test, P=0.001). Patients with HG had a higher chance of getting aortic valve replacement (AVR) than those with LF/LG and NF/LG (20.7% NF/HG vs. 10.6% LF/HG vs. 4.7% LF/LG and 3.6% NF/LG; P=0.01). Patients who underwent AVR had lower mortality rates when compared with the overall cohort in all subgroups (LF/HG 21.4% vs. 18.9% NF/HG vs. 6.6% LF/LG and 7.1% NF/LG; Log Rank Test, P= 0.253). Conclusion: Patients with LF/LG represent an under-recognized high-risk group with similar prognosis to NF/HG. Although these patients may benefit tremendously from AVR, they are less likely to undergo AVR when compared to HG patients.

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