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Clinical Outcomes in Different Types of Aortic Stenosis as Assessed by Doppler Echocardiography
R Brandon Stacey1, Meng Meng2, Graham V Byrum Iii2
1Departments of Internal Medicine Section on Cardiology, School of Medicine, Winston-Salem, North Carolina, USA. Electronic correspondence: bstacey@wfubmc.edu.
Insights
Low-gradient, severe aortic stenosis (AS) with preserved ejection fraction (EF) has a worse prognosis than moderate AS. Patients with low-gradient severe AS and reduced EF face the highest mortality risk.
Area of Science:
- Cardiology
- Echocardiography
- Valvular Heart Disease
Background:
- Cardiologists face challenges in determining the prognosis of low-gradient, severe aortic stenosis (AS) with preserved ejection fraction (EF).
- Conflicting data complicates decision-making for these patients.
- This study aimed to clarify the prognosis and significance of severe AS using echocardiography data.
Purpose of the Study:
- To determine the prognosis and clinical significance of severe aortic stenosis (AS) with varying pressure gradients and ejection fractions (EF).
- To stratify risk among patients with severe AS based on echocardiographic parameters.
Main Methods:
- Retrospective analysis of 302 patients with severe AS (aortic valve area ≤1.0 cm²) from 2010-2011.
- Patients were categorized into four groups: PG-matched severe AS, low-PG severe AS with reduced EF (<50%), low-PG severe AS with preserved EF (≥50%), and moderate AS.
- Outcomes were compared between medically managed and surgically treated patients.
Main Results:
- Patients with low-gradient severe AS and reduced EF (<50%) had the worst outcomes among medically managed individuals.
- Low-gradient severe AS with reduced EF (<50%) and PG-matched severe AS were associated with increased mortality risk compared to low-gradient severe AS with preserved EF (≥50%).
- Both unoperated PG-matched severe AS and medically managed low-PG severe AS with preserved EF showed significantly higher mortality risk compared to surgical intervention.
Conclusions:
- Low-gradient severe AS with preserved EF indicates a worse survival than moderate AS.
- However, survival in low-gradient severe AS with preserved EF is better than in gradient-matched severe AS.
- Risk stratification based on gradient and EF is crucial for managing severe AS.
Background And Aim Of The Study:
Cardiologists continue to struggle with the prognosis and significance of low-gradient, severe aortic stenosis (AS) with preserved ejection fraction (EF). Conflicting data makes more substantive decisions challenging. The study aim was to determine the prognosis and significance of severe AS by reviewing index cases from the authors' echocardiography laboratory.
Methods:
The study included 302 patients with AS and with aortic valve area (AVA) ≤1.0 cm2 who were identified from the echocardiography database between 2010 and 2011. AS was subdivided into four types based on AVA and mean pressure gradient (PG): (i) PG-matched, severe AS (AVA ≤1.0 cm2 and mean PG ≥40 mmHg; n = 143); (ii) low-PG, severe AS (AVA ≤1.0 cm2, mean PG <40 mmHg, and reduced EF <50%; n = 52); (iii) low-PG, severe AS (AVA ≤1.0 cm2, mean PG <40 mmHg, preserved EF ≥50%; n = 107); and patients with moderate AS (mean PG >25 mmHg and AVA ≥1.0 cm2; n = 104).
Results:
Among patients medically managed, those with low-PG severe AS and a reduced EF had the worst outcome. Compared to low-PG severe AS with EF ≥50%, patients with a low-PG and severe AS with EF <50%, and with matched-PG severe AS, had an increased risk of death (p <0.001 and p = 0.052, respectively). For gradient-matched severe AS, those patients who were unoperated had a more than five-fold mortality risk compared to those who underwent surgery [Hazard Ratio (HR): 5; p <0.001]. Similarly, among patients with low-PG severe AS with EF ≥50%, those medically managed had a threefold greater mortality risk compared to those who underwent surgery (HR: 3.3; p = 0.002).
Conclusions:
Patients with low-PG severe AS and a preserved EF have a worse survival than those with moderate AS, but survived better than those with gradient-matched severe AS.
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