Diastolic transmitral valve pressure gradients in patients with severe calcific aortic stenosis

Abstract

During hemodynamic assessment prior to antegrade balloon aortic valvuloplasty (BAV), unanticipated transmitral valve pressure gradients (MVG) were noted frequently. To determine the prevalence and significance of a significant MVG in patients with aortic stenosis and no previously diagnosed mitral valve stenosis. Retrospective chart review of patients with severe aortic stenosis who underwent antegrade BAV. During antegrade BAV, direct transseptal left atrial (LA) and left ventricular (LV) pressure measurements were obtained allowing for accurate assessment of MVG. Significant MVG is defined as a LA-LV gradient of > or =5 mm Hg. Eighty-two BAV patients were reviewed (mean age 84 +/- 8.9 years, mean additive Euroscore 10.5 +/- 2.2). The mean MVG was 5.0 +/- 3.5 mm Hg (range 0-14 mm Hg). A significant MVG was seen in 54.9% and, compared with no significant MVG, was associated at with significantly higher LA mean pressure (26.0 +/- 6.0 mm Hg vs. 16.8 +/- 6.6 mm Hg, P < 0.001), higher pulmonary arterial systolic pressure (59.3 +/- 14.7 mm Hg vs. 43.1 +/- 16.5 mm Hg, P < 0.001), and higher pulmonary mean systolic pressure (37.7 +/- 10.4 mm Hg vs. 28.0 +/- 11.4 mm Hg, P < 0.001). Statistically significant correlations were seen between MVG and LA mean pressure (r = 0.65, P < 0.001), pulmonary arterial systolic (r = 0.49, P < 0.001) and pulmonary arterial mean pressures (r = 0.41, P < 0.001). There was no association with cardiovascular risk factors, with presence or severity of mitral annular calcification (visually assessed on cine-fluoroscopy) or with the presence of mitral regurgitation. A significant MVG is commonly seen in patients with severe calcific aortic stenosis and is associated with higher pulmonary arterial and left atrial pressures.