scholarly journals Prevalence and Outcomes of Low‐Gradient Severe Aortic Stenosis—From the National Echo Database of Australia

2021 ◽  
Author(s):  
Afik D. Snir ◽  
Martin K. Ng ◽  
Geoff Strange ◽  
David Playford ◽  
Simon Stewart ◽  
...  
Keyword(s):  
Left Ventricular Ejection Fraction ◽  
Aortic Stenosis ◽  
Ejection Fraction ◽  
Left Ventricular ◽  
Ventricular Ejection ◽  
Volume Index ◽  
Left Ventricular Ejection ◽  
Normal Flow ◽  
Ventricular Ejection Fraction ◽  
High Gradient

Background The prevalence and outcomes of the different subtypes of severe low‐gradient aortic stenosis (AS) in routine clinical cardiology practice have not been well characterized. Methods and Results Data were derived from the National Echocardiography Database of Australia. Of 192 060 adults (aged 62.8±17.8 [mean±SD] years) with native aortic valve profiling between 2000 and 2019, 12 013 (6.3%) had severe AS. Of these, 5601 patients (47%) had high‐gradient and 6412 patients (53%) had low‐gradient severe AS. The stroke volume index was documented in 2741 (42.7%) patients with low gradient; 1750 patients (64%) with low flow, low gradient (LFLG); and 991 patients with normal flow, low gradient. Of the patients with LFLG, 1570 (89.7%) had left ventricular ejection fraction recorded; 959 (61%) had paradoxical LFLG (preserved left ventricular ejection fraction), and 611 (39%) had classical LFLG (reduced left ventricular ejection fraction). All‐cause and cardiovascular‐related mortality were assessed in the 8162 patients with classifiable severe AS subtype during a mean±SD follow‐up of 88±45 months. Actual 1‐year and 5‐year all‐cause mortality rates varied across these groups and were 15.8% and 49.2% among patients with high‐gradient severe AS, 11.6% and 53.6% in patients with normal‐flow, low‐gradient severe AS, 16.9% and 58.8% in patients with paradoxical LFLG severe AS, and 30.5% and 72.9% in patients with classical LFLG severe AS. Compared with patients with high‐gradient severe AS, the 5‐year age‐adjusted and sex‐adjusted mortality risk hazard ratios were 0.94 (95% CI, 0.85–1.03) in patients with normal‐flow, low‐gradient severe AS; 1.01 (95% CI, 0.92–1.12) in patients with paradoxical LFLG severe AS; and 1.65 (95% CI, 1.48–1.84) in patients with classical LFLG severe AS. Conclusions Approximately half of those patients with echocardiographic features of severe AS in routine clinical practice have low‐gradient hemodynamics, which is associated with long‐term mortality comparable with or worse than high‐gradient severe AS. The poorest survival was associated with classical LFLG severe AS.

Abstract 19266: Derivation of Risk Score in Predicting Deterioration in Left Ventricular Ejection Fraction in Patients With Low-flow Significant Aortic Stenosis and Initially Preserved Ejection Fraction

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Benjamin Y Tan ◽  
Nicholas J Ngiam ◽  
Glenn Lee ◽  
Yiong-Huak Chan ◽  
Kian-Keong Poh
Keyword(s):  
Left Ventricular Ejection Fraction ◽  
Aortic Stenosis ◽  
Ejection Fraction ◽  
Risk Score ◽  
Left Ventricular ◽  
Ventricular Ejection ◽  
Low Flow ◽  
Volume Index ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction

Introduction: Low-flow significant aortic stenosis (AS) with preserved left ventricular ejection fraction (LVEF>50%) is associated with worse clinical outcomes. In classical severe AS, guidelines have indicated that deterioration of LVEF to <50% is a Class I indication for aortic valve replacement. However, predictors of LVEF deterioration in patients with low-flow AS have not been studied. We developed a model, based on clinical and echocardiographic parameters to predict LVEF deterioration to <50%. Methods: Consecutive subjects (n=162) with low-flow (stroke volume index <35mg/ml) significant AS and paired echocardiographic studies (>180 days apart) were studied. Significant predictors of LVEF deterioration on univariate analyses were fit into a multivariable logistic regression. A risk score was then developed by converting the B-coefficients into weights, and its performance in predicting the LVEF deterioration to <50% was evaluated. Results: There were 50 patients (30.9%) with significant deterioration of LVEF to <50% from baseline. A risk score was developed based on five clinical and echocardiographic predictors (History of hypertension (p=0.008) – 1 point, initial LVEF <65% (p=0.012) – 2 points, Tissue Doppler S’ velocity <7.3cm/s (p=0.049) – 1 point, End-systolic wall stress >70g/cm2 (p=0.001) – 2 points, and left ventricular mass index >100g/m2 (p=0.010) – 1 point). The risk score performed well under receiver operating characteristic curve (AUC=0.78, 95%CI 0.72-0.85, p<0.001). A score of 4 points or more was the optimal cut-off, predicting most cases (98%, 48 out of 50). Conclusions: Despite preserved LVEF, subclinical myocardial dysfunction may represent an important comorbidity in patients with low-flow AS, which may accelerate inappropriate left ventricular remodelling. The risk score may be used to identify patients at risk of significant LVEF deterioration, thereby allowing for closer monitoring and earlier surgical intervention.

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