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Flow-gradient patterns in severe aortic stenosis with preserved ejection fraction: clinical characteristics and
Mackram F Eleid1, Paul Sorajja, Hector I Michelena
1Division of Cardiovascular Diseases, Department of Medicine (M.F.E., P.S., H.I.M., J.F.M., P.A.P.), and Division of Biostatistics (C.G.S.), Mayo Clinic College of Medicine, Rochester, MN.
Insights
Patients with severe aortic stenosis and normal ejection fraction have varying prognoses based on flow and gradient. Low flow/low gradient severe aortic stenosis indicates poor survival, but aortic valve replacement improves outcomes.
Area of Science:
- Cardiology
- Echocardiography
- Valvular Heart Disease
Background:
- Severe aortic stenosis (AS) with preserved ejection fraction (PEF) can present with low gradient (LG) and reduced stroke volume, potentially indicating an adverse prognosis.
- The recently proposed flow-gradient classification offers a new method to stratify patients and assess prognosis in severe AS with PEF.
Purpose of the Study:
- To investigate the prognostic impact of stroke volume in patients with severe aortic stenosis and preserved ejection fraction.
- To evaluate the utility of the flow-gradient classification in stratifying risk and guiding management in this patient population.
Main Methods:
- A cohort of 1704 consecutive patients with severe AS (aortic valve area <1.0 cm(2)) and PEF (≥50%) was analyzed using 2D and Doppler echocardiography.
- Patients were stratified into four groups based on stroke volume index (low flow [LF] <35 mL/m(2) vs. normal flow [NF] ≥35 mL/m(2)) and aortic gradient (LG <40 mm Hg vs. high gradient [HG] ≥40 mm Hg): NF/HG, NF/LG, LF/HG, and LF/LG.
- Survival rates and the impact of aortic valve replacement (AVR) were assessed for each group using multivariable analysis.
Main Results:
- Normal flow/low gradient (NF/LG) severe AS was associated with favorable survival under medical management (2-year estimate: 82%).
- Low flow/low gradient (LF/LG) severe AS (3% of patients) exhibited reduced ejection fraction, higher prevalence of atrial fibrillation and heart failure, decreased arterial compliance, and significantly reduced survival (2-year estimate: 60%).
- The LF/LG pattern was the strongest predictor of mortality (HR, 3.26). AVR significantly reduced mortality in LF/LG and NF/HG groups (HR, 0.31) but showed no survival benefit in NF/LG and LF/HG groups.
Conclusions:
- Severe AS with PEF and a normal flow/low gradient pattern demonstrates favorable survival with medical management, with neutral impact from AVR.
- Severe AS with PEF and a low flow/low gradient pattern is linked to high rates of comorbidities and reduced survival; AVR is associated with improved survival in this subgroup.
- These findings underscore the importance of the flow-gradient classification for accurate risk stratification and personalized management decisions in severe AS with PEF.
Background:
Among patients with severe aortic stenosis (AS) and preserved ejection fraction, those with low gradient (LG) and reduced stroke volume may have an adverse prognosis. We investigated the prognostic impact of stroke volume using the recently proposed flow-gradient classification.
Methods And Results:
We examined 1704 consecutive patients with severe AS (aortic valve area <1.0 cm(2)) and preserved ejection fraction (≥50%) using 2-dimensional and Doppler echocardiography. Patients were stratified by stroke volume index (<35 mL/m(2) [low flow, LF] versus ≥35 mL/m(2) [normal flow, NF]) and aortic gradient (<40 mm Hg [LG] versus ≥40 mm Hg [high gradient, HG]) into 4 groups: NF/HG, NF/LG, LF/HG, and LF/LG. NF/LG (n=352, 21%), was associated with favorable survival with medical management (2-year estimate, 82% versus 67% in NF/HG; P<0.0001). LF/LG severe AS (n=53, 3%) was characterized by lower ejection fraction, more prevalent atrial fibrillation and heart failure, reduced arterial compliance, and reduced survival (2-year estimate, 60% versus 82% in NF/HG; P<0.001). In multivariable analysis, the LF/LG pattern was the strongest predictor of mortality (hazard ratio, 3.26; 95% confidence interval, 1.71-6.22; P<0.001 versus NF/LG). Aortic valve replacement was associated with a 69% mortality reduction (hazard ratio, 0.31; 95% confidence interval, 0.25-0.39; P<0.0001) in LF/LG and NF/HG, with no survival benefit associated with aortic valve replacement in NF/LG and LF/HG.
Conclusions:
NF/LG severe AS with preserved ejection fraction exhibits favorable survival with medical management, and the impact of aortic valve replacement on survival was neutral. LF/LG severe AS is characterized by a high prevalence of atrial fibrillation, heart failure, and reduced survival, and aortic valve replacement was associated with improved survival. These findings have implications for the evaluation and subsequent management of AS severity.
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