Echocardiography and EuroSCORE II for the stratification of low-gradient severe aortic stenosis and preserved left ventricular ejection fraction

Yan Fan,Robert J Applegate,Edward H Kincaid,Sanjay K Gandhi,Hong Shen,Min Pu,Brandon Stacey,Neal D Kon,David Zhao

doi:10.1007/s10554-021-02373-2

Abstract

The purpose of this study was to explore the utility of echocardiography and the EuroSCORE II in stratifying patients with low-gradient severe aortic stenosis (LG SAS) and preserved left ventricular ejection fraction (LVEF ≥ 50%) with or without aortic valve intervention (AVI). The study included 323 patients with LG SAS (aortic valve area ≤ 1.0 cm2 and mean pressure gradient < 40 mmHg). Patients were divided into two groups: a high-risk group (EuroSCORE II ≥ 4%, n = 115) and a low-risk group (EuroSCORE II < 4%, n = 208). Echocardiographic and clinical characteristics were analyzed. All-cause mortality was used as a clinical outcome during mean follow-up of 2 ± 1.3 years. Two-year cumulative survival was significantly lower in the high-risk group than the low-risk patients (62.3% vs. 81.7%, p = 0.001). AVI tended to reduce mortality in the high-risk patients (70% vs. 59%; p = 0.065). It did not significantly reduce mortality in the low-risk patients (82.8% with AVI vs. 81.2%, p = 0.68). Multivariable analysis identified heart failure, renal dysfunction and stroke volume index (SVi) as independent predictors for mortality. The study suggested that individualization of AVI based on risk stratification could be considered in a patient with LG SAS and preserved LVEF.

Highlights

The American College of Cardiology/American Heart Association guidelines established the criteria for diagnosis of severe aortic stenosis (SAS) as a peak aortic peak velocity (Vmax) ≥ 4.0 m/s, a mean transaortic pressure gradient (MPG) ≥ 40 mmHg and an aortic valve area (AVA) ≤ 1.0 cm2 [1]
We hypothesized that clinical outcome in patients with low-gradient severe aortic stenosis (LG SAS) and preserved left ventricular ejection fraction (LVEF) may be associated with multiple risk factors, comorbidities and certain echocardiographic features
The aim of the study was to assess whether combination of echocardiographic assessment and EuroSCORE II could be useful for stratifying patients with LG SAS and preserved LVEF

Summary

Introduction

The American College of Cardiology/American Heart Association guidelines established the criteria for diagnosis of severe aortic stenosis (SAS) as a peak aortic peak velocity (Vmax) ≥ 4.0 m/s, a mean transaortic pressure gradient (MPG) ≥ 40 mmHg and an aortic valve area (AVA) ≤ 1.0 cm2 [1]. Doppler study shows a low-flow (SVi = 29 ml/m2), low-gradient (mean gradient = 27 mmHg) and a small calculated AVA = 0.73 cm; D TEE often demonstrates calcified aortic valve improvement in LV global longitudinal strain, LV mass or neurohormonal activation [14]. With such a discrepancy in natural history, the choice of treatment of LG SAS needs further investigation [15].

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