Refereed journal article or data article (A1)
Prevalence and Prognostic Implications of Discordant Grading and Flow-Gradient Patterns in Moderate Aortic Stenosis
List of Authors: Stassen Jan, Ewe See Hooi, Singh GurpreetK, Butcher Steele C, Hirasawa Kensuke, Amanullah Mohammed R, Pio Stephan M, Sin Kenny YK, Ding Zee P, Sia Ching-Hui, Chew Nicholas WS, Kong William KF, Poh Kian Keong, Leon Martin B, Pibarot Philippe, Delgado Victoria, Marsan Nina Ajmone, Bax Jeroen J
Publisher: Elsevier Inc
Publication year: 2022
Journal: Journal of the American College of Cardiology
Journal name in source: Journal of the American College of Cardiology
Volume number: 80
Issue number: 7
Start page: 666
End page: 676
eISSN: 1558-3597
DOI: http://dx.doi.org/10.1016/j.jacc.2022.05.036
URL: https://doi.org/10.1016/j.jacc.2022.05.036
BACKGROUND The prognostic implications of discordant grading in severe aortic stenosis (AS) are well known. However, the prevalence of different flow-gradient patterns and their prognostic implications in moderate AS are unknown.
OBJECTIVES The purpose of this study was to investigate the occurrence and prognostic implications of different flow-gradient patterns in patients with moderate AS.
METHODS Patients with moderate AS (aortic valve area >1.0 and #1.5 cm2) were identified and divided in 4 groups based on transvalvular mean gradient (MG), stroke volume index (SVi), and left ventricular ejection fraction (LVEF): concordant moderate AS (MG $20 mm Hg) and discordant moderate AS including 3 subgroups: normal-flow, low-gradient moderate AS (MG <20 mm Hg, SVi $35 mL/m2, and LVEF $50%); “paradoxical” low-flow, low-gradient moderate AS (MG <20 mm Hg, SVi <35 mL/m2, and LVEF $50%) and “classical” low-flow, low-gradient moderate AS (MG <20 mm Hg and LVEF <50%). The primary endpoint was all-cause mortality.
RESULTS Of 1,974 patients (age 73 10 years, 51% men) with moderate AS, 788 (40%) had discordant grading, and these patients showed significantly higher mortality rates than patients with concordant moderate AS (P < 0.001). On multivariable analysis, “paradoxical” low-flow, low-gradient (HR: 1.458; 95% CI: 1.072-1.983; P ¼ 0.014) and “classical” low-flow, low-gradient (HR: 1.710; 95% CI: 1.270-2.303; P < 0.001) patterns but not the normal-flow, low-gradient moderate AS pattern were independently associated with all-cause mortality.
CONCLUSIONS Discordant grading is frequently (40%) observed in patients with moderate AS. Low-flow, low- gradient patterns account for an important proportion of the discordant cases and are associated with increased mortality. These findings underline the need for better phenotyping patients with discordant moderate AS.
