Management of aortic valve replacement according to the gradient across symptomatic aortic valve stenosis and its prognostic impact.

Abstract

Treatment strategy for low-gradient (LG) aortic stenosis (AS) remains an unresolved issue. The presence of a low aortic gradient and preserved left ventricular ejection fraction (LVEF) might lead toward the underestimation of aortic stenosis severity and a more conservative management. We sought (a) to describe the nature and timing of intervention according to flow/gradient subgroups in patibents with LG-AS, (2) to determine the factors associated with the decision to intervene, and (c) to describe prognosis. One hundred and ten patients prospectively included in this study underwent a standardized clinical and imaging evaluation at inclusion and at 1-year follow-up. According to aortic flow, gradient and LVEF, patients were divided into 4 groups: LG-normal flow [n=27], LG-low flow-low LVEF [n=27], LG-low flow-normal LVEF [n=16], and high gradient (HG) [n=40]). 73% of patients underwent AVR 86±59days after the initial assessment. The HG subgroup had significantly higher intervention rates (P<.001). In multivariable analysis, four parameters were associated with the AVR: aortic gradient (HR 1.52 [1.10-2.11], P=.012), LVEF (HR 0.58 [0.40-0.85], P=.006), atrial fibrillation (HR 0.43 [0.021-0.87], P=.019), and NT-proBNP (HR 0.92[0.86-0.98), P=.008]. Patients operated earlier had better outcomes than those having a delayed AVR (P=.042). LG-AS patients had worse outcomes than HG-AS patients (P<.001). Compared to HG-AS, LG-AS is less likely to benefit from an AVR and had a significantly worse outcome. Further interventional studies are needed to investigate the timing of AVR in these patients.