Ezequiel Guzzetti1, Anthony Poulin1, Mohamed-Salah Annabi1, Bin Zhang1, Dimitri Kalavrouziotis2, Christian Couture3, François Dagenais2, Philippe Pibarot4, Marie-Annick Clavel5. 1. Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada. 2. Department of Cardiac Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada. 3. Department of Anatomo-Pathology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada. 4. Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada. Electronic address: https://twitter.com/PPibarot. 5. Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada. Electronic address: marie-annick.clavel@criucpq.ulaval.ca.
Abstract
BACKGROUND: The respective impacts of transvalvular flow, gradient, sex, and their interactions on mortality in patients with severe aortic stenosis undergoing surgical aortic valve replacement (AVR) are unknown. OBJECTIVES: This study sought to compare the impact of pre-operative flow-gradient patterns on mortality after AVR and to examine whether there are sex differences. METHODS: This study analyzed clinical, echocardiographic, and outcome data prospectively collected in 1,490 patients (544 women [37%]), with severe aortic stenosis and preserved left ventricular ejection fraction who underwent AVR. RESULTS: In this cohort, 601 patients (40%) had normal flow (NF) with high gradient (HG), 405 (27%) NF with low gradient (LG), 246 (17%) paradoxical low flow (LF)/HG, and 238 (16%) LF/LG. During a median follow-up of 2.42 years (interquartile range: 1.04 to 4.29 years), 167 patients died. Patients with LF/HG exhibited the highest mortality after AVR (hazard ratio [HR]: 2.01; 95% confidence interval [CI]: 1.33 to 3.03; p < 0.01), which remained significant after multivariate adjustment (HR: 1.96; 95% CI: 1.29 to 2.98; p < 0.01). Both LF/LG and NF/LG patients had comparable outcome to NF/HG (p ≥ 0.47). Optimal thresholds of stroke volume index were obtained for men (40 ml/m2) and women (32 ml/m2). Using these sex-specific cutpoints, paradoxical LF was independently associated with increased mortality in both women (adjusted HR: 2.05; 95% CI: 1.21 to 3.47; p < 0.01) and men (adjusted HR: 1.54; 95% CI: 1.02 to 2.32; p = 0.042), whereas guidelines' threshold (35 ml/m2) does not. CONCLUSIONS: Paradoxical LF/HG was associated with higher mortality following AVR, suggesting that a reduced flow is a marker of disease severity even in patients with HG aortic stenosis. Early surgical AVR (i.e., before gradient attains 40 mm Hg) might be preferable in these patients. Furthermore, the use of sex-specific thresholds (<40 ml/m2 for men and <32 ml/m2 for women) to define low-flow outperforms the guidelines' threshold of 35 ml/m2 in risk stratification after AVR.
BACKGROUND: The respective impacts of transvalvular flow, gradient, sex, and their interactions on mortality in patients with severe aortic stenosis undergoing surgical aortic valve replacement (AVR) are unknown. OBJECTIVES: This study sought to compare the impact of pre-operative flow-gradient patterns on mortality after AVR and to examine whether there are sex differences. METHODS: This study analyzed clinical, echocardiographic, and outcome data prospectively collected in 1,490 patients (544 women [37%]), with severe aortic stenosis and preserved left ventricular ejection fraction who underwent AVR. RESULTS: In this cohort, 601 patients (40%) had normal flow (NF) with high gradient (HG), 405 (27%) NF with low gradient (LG), 246 (17%) paradoxical low flow (LF)/HG, and 238 (16%) LF/LG. During a median follow-up of 2.42 years (interquartile range: 1.04 to 4.29 years), 167 patientsdied. Patients with LF/HG exhibited the highest mortality after AVR (hazard ratio [HR]: 2.01; 95% confidence interval [CI]: 1.33 to 3.03; p < 0.01), which remained significant after multivariate adjustment (HR: 1.96; 95% CI: 1.29 to 2.98; p < 0.01). Both LF/LG and NF/LG patients had comparable outcome to NF/HG (p ≥ 0.47). Optimal thresholds of stroke volume index were obtained for men (40 ml/m2) and women (32 ml/m2). Using these sex-specific cutpoints, paradoxical LF was independently associated with increased mortality in both women (adjusted HR: 2.05; 95% CI: 1.21 to 3.47; p < 0.01) and men (adjusted HR: 1.54; 95% CI: 1.02 to 2.32; p = 0.042), whereas guidelines' threshold (35 ml/m2) does not. CONCLUSIONS: Paradoxical LF/HG was associated with higher mortality following AVR, suggesting that a reduced flow is a marker of disease severity even in patients with HG aortic stenosis. Early surgical AVR (i.e., before gradient attains 40 mm Hg) might be preferable in these patients. Furthermore, the use of sex-specific thresholds (<40 ml/m2 for men and <32 ml/m2 for women) to define low-flow outperforms the guidelines' threshold of 35 ml/m2 in risk stratification after AVR.
Authors: Jacqueline T DesJardin; Joanna Chikwe; Rebecca T Hahn; Judy W Hung; Francesca N Delling Journal: Circ Res Date: 2022-02-17 Impact factor: 17.367
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