High-Gradient Aortic Stenosis With Valve Area >1.0 cm²: The "Forgotten" Discordant Hemodynamic Phenotype

Area of Science:

• Cardiology
• Echocardiography
• Valvular Heart Disease

Background:

• Severe aortic stenosis (AS) classification relies on hemodynamic phenotypes.
• Understanding clinical features and outcomes across different AS phenotypes is crucial.

Purpose of the Study:

• To investigate the clinical characteristics and prognosis of patients with high-gradient (HG) AS defined by an aortic valve area (AVA) greater than 1.0 cm².
• To compare outcomes between different AS hemodynamic phenotypes.

Main Methods:

• Retrospective analysis of 3,209 patients with AS.
• Phenotyping based on AVA (cm²), peak velocity (m/s), and mean pressure gradient (MG) (mmHg).
• Classifications included HG-AVA >1 (>1.0 cm², ≥4 m/s, ≥40 mmHg), HG-AVA ≤1 (≤1.0 cm², ≥4 m/s, ≥40 mmHg), LG-AVA ≤1 (≤1.0 cm², <4 m/s, <40 mmHg), and moderate AS.

Main Results:

• The HG-AVA >1 group (7.2% of patients) was younger, predominantly male, had fewer comorbidities, larger body surface area and stroke volume, and a higher prevalence of bicuspid valves.
• Unadjusted all-cause mortality was higher in HG-AVA ≤1, LG-AVA ≤1, and moderate AS groups compared to HG-AVA >1.
• After adjustment for covariates, mortality differences were not significant. Patients with HG-AVA >1 who underwent aortic valve replacement showed improved survival.

Conclusions:

• The HG-AVA >1 phenotype is associated with a relative high-flow status and a better prognosis, linked to younger age and better overall health.
• Despite a favorable prognosis, aortic valve replacement may offer survival benefits in the HG-AVA >1 population.