BACKGROUND: Among patients with severe aortic stenosis (AS) and preserved ejection fraction, those with low gradient (LG) and reduced stroke volume may have an adverse prognosis. We investigated the prognostic impact of stroke volume using the recently proposed flow-gradient classification. METHODS AND RESULTS: We examined 1704 consecutive patients with severe AS (aortic valve area <1.0 cm(2)) and preserved ejection fraction (≥50%) using 2-dimensional and Doppler echocardiography. Patients were stratified by stroke volume index (<35 mL/m(2) [low flow, LF] versus ≥35 mL/m(2) [normal flow, NF]) and aortic gradient (<40 mm Hg [LG] versus ≥40 mm Hg [high gradient, HG]) into 4 groups: NF/HG, NF/LG, LF/HG, and LF/LG. NF/LG (n=352, 21%), was associated with favorable survival with medical management (2-year estimate, 82% versus 67% in NF/HG; P<0.0001). LF/LG severe AS (n=53, 3%) was characterized by lower ejection fraction, more prevalent atrial fibrillation and heart failure, reduced arterial compliance, and reduced survival (2-year estimate, 60% versus 82% in NF/HG; P<0.001). In multivariable analysis, the LF/LG pattern was the strongest predictor of mortality (hazard ratio, 3.26; 95% confidence interval, 1.71-6.22; P<0.001 versus NF/LG). Aortic valve replacement was associated with a 69% mortality reduction (hazard ratio, 0.31; 95% confidence interval, 0.25-0.39; P<0.0001) in LF/LG and NF/HG, with no survival benefit associated with aortic valve replacement in NF/LG and LF/HG. CONCLUSIONS: NF/LG severe AS with preserved ejection fraction exhibits favorable survival with medical management, and the impact of aortic valve replacement on survival was neutral. LF/LG severe AS is characterized by a high prevalence of atrial fibrillation, heart failure, and reduced survival, and aortic valve replacement was associated with improved survival. These findings have implications for the evaluation and subsequent management of AS severity.
BACKGROUND: Among patients with severe aortic stenosis (AS) and preserved ejection fraction, those with low gradient (LG) and reduced stroke volume may have an adverse prognosis. We investigated the prognostic impact of stroke volume using the recently proposed flow-gradient classification. METHODS AND RESULTS: We examined 1704 consecutive patients with severe AS (aortic valve area <1.0 cm(2)) and preserved ejection fraction (≥50%) using 2-dimensional and Doppler echocardiography. Patients were stratified by stroke volume index (<35 mL/m(2) [low flow, LF] versus ≥35 mL/m(2) [normal flow, NF]) and aortic gradient (<40 mm Hg [LG] versus ≥40 mm Hg [high gradient, HG]) into 4 groups: NF/HG, NF/LG, LF/HG, and LF/LG. NF/LG (n=352, 21%), was associated with favorable survival with medical management (2-year estimate, 82% versus 67% in NF/HG; P<0.0001). LF/LG severe AS (n=53, 3%) was characterized by lower ejection fraction, more prevalent atrial fibrillation and heart failure, reduced arterial compliance, and reduced survival (2-year estimate, 60% versus 82% in NF/HG; P<0.001). In multivariable analysis, the LF/LG pattern was the strongest predictor of mortality (hazard ratio, 3.26; 95% confidence interval, 1.71-6.22; P<0.001 versus NF/LG). Aortic valve replacement was associated with a 69% mortality reduction (hazard ratio, 0.31; 95% confidence interval, 0.25-0.39; P<0.0001) in LF/LG and NF/HG, with no survival benefit associated with aortic valve replacement in NF/LG and LF/HG. CONCLUSIONS: NF/LG severe AS with preserved ejection fraction exhibits favorable survival with medical management, and the impact of aortic valve replacement on survival was neutral. LF/LG severe AS is characterized by a high prevalence of atrial fibrillation, heart failure, and reduced survival, and aortic valve replacement was associated with improved survival. These findings have implications for the evaluation and subsequent management of AS severity.
Authors: Roberto M Lang; Michelle Bierig; Richard B Devereux; Frank A Flachskampf; Elyse Foster; Patricia A Pellikka; Michael H Picard; Mary J Roman; James Seward; Jack S Shanewise; Scott D Solomon; Kirk T Spencer; Martin St John Sutton; William J Stewart Journal: J Am Soc Echocardiogr Date: 2005-12 Impact factor: 5.251
Authors: Helmut Baumgartner; Judy Hung; Javier Bermejo; John B Chambers; Arturo Evangelista; Brian P Griffin; Bernard Iung; Catherine M Otto; Patricia A Pellikka; Miguel Quiñones Journal: J Am Soc Echocardiogr Date: 2009-01 Impact factor: 5.251
Authors: J K Oh; C P Taliercio; D R Holmes; G S Reeder; K R Bailey; J B Seward; A J Tajik Journal: J Am Coll Cardiol Date: 1988-06 Impact factor: 24.094
Authors: Martin Briand; Jean G Dumesnil; Lyes Kadem; Antonio G Tongue; Régis Rieu; Damien Garcia; Philippe Pibarot Journal: J Am Coll Cardiol Date: 2005-07-19 Impact factor: 24.094
Authors: Rick A Nishimura; J Aaron Grantham; Heidi M Connolly; Hartzell V Schaff; Stuart T Higano; David R Holmes Journal: Circulation Date: 2002-08-13 Impact factor: 29.690
Authors: Hector I Michelena; Edit Margaryan; Fletcher A Miller; Mackram Eleid; Joseph Maalouf; Rakesh Suri; David Messika-Zeitoun; Patricia A Pellikka; Maurice Enriquez-Sarano Journal: Heart Date: 2013-01-24 Impact factor: 5.994
Authors: Howard C Herrmann; Philippe Pibarot; Irene Hueter; Zachary M Gertz; William J Stewart; Samir Kapadia; E Murat Tuzcu; Vasilis Babaliaros; Vinod Thourani; Wilson Y Szeto; Joseph E Bavaria; Susheel Kodali; Rebecca T Hahn; Mathew Williams; D Craig Miller; Pamela S Douglas; Martin B Leon Journal: Circulation Date: 2013-05-09 Impact factor: 29.690
Authors: Jinghao Nicholas Ngiam; Nicholas Chew; Rebecca Teng; Jonathan D Kochav; Stephanie M Kochav; Benjamin Yong-Qiang Tan; Hui Wen Sim; Ching-Hui Sia; William K F Kong; Edgar Lik Wui Tay; Tiong-Cheng Yeo; Kian-Keong Poh Journal: Int J Cardiovasc Imaging Date: 2019-11-27 Impact factor: 2.357
Authors: Nisha Hosadurg; Benjamin Koethe; Dou Huang; Andrew R Weintraub; Ayan R Patel; Benjamin S Wessler Journal: J Am Soc Echocardiogr Date: 2020-09-02 Impact factor: 5.251
Authors: Shiying Liu; Jessica Churchill; Lanqi Hua; Xin Zeng; Valerie Rhoades; Mayooran Namasivayam; Vinit Baliyan; Brian B Ghoshhajra; Tony Dong; Jacob P Dal-Bianco; Jonathan J Passeri; Robert A Levine; Judy Hung Journal: J Am Soc Echocardiogr Date: 2020-04 Impact factor: 5.251