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Discordant Grading and Flow-Gradient Patterns in Moderate Aortic Stenosis
Quick Takes
- Discordant grading is frequently observed in patients with moderate aortic stenosis (AS) and is associated with increased risk of mortality compared with concordant moderate AS.
- Among those with discordant grading, the paradoxical and classical low-flow, low-gradient patterns but not the normal-flow, low-gradient pattern were independently associated with worse outcomes.
- Clinical studies are indicated to assess whether aortic valve replacement at an earlier stage may be beneficial in patients with “classical” and “paradoxical” low-flow, low-gradient moderate AS to improve clinical outcomes.
Study Questions:
What is the occurrence and what are the prognostic implications of different flow-gradient patterns in patients with moderate aortic stenosis (AS)?
Methods:
The investigators identified patients with moderate AS (aortic valve area >1.0 and ≤1.5 cm2) and divided into four 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 three 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. Event-free survival curves were generated using the Kaplan-Meier method, and differences between groups were analyzed using the log-rank test.
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 (hazard ratio [HR], 1.458; 95% confidence interval [CI], 1.072-1.983; p = 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:
The authors reported that low-flow, low-gradient patterns account for an important proportion of the discordant AS cases and are associated with increased mortality.
Perspective:
This study reports that discordant grading is frequently observed in patients with moderate AS and is associated with increased risk of mortality compared with concordant moderate AS. Overall, the normal-flow, low-gradient pattern accounted for the majority (55%) of discordant cases, whereas the classical low-flow, low-gradient pattern was seen in 31% and the paradoxical low-flow, low-gradient pattern in 14% of cases. Furthermore, among those with discordant grading, the paradoxical and classical low-flow, low-gradient patterns but not the normal-flow, low-gradient pattern were independently associated with worse outcomes. These findings highlight a need to better phenotype patients with discordant moderate AS. In addition, clinical studies are indicated to assess whether aortic valve replacement at an earlier stage may be beneficial in patients with “classical” and “paradoxical” low-flow, low-gradient moderate AS to improve clinical outcomes.
Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Imaging, Interventions and Structural Heart Disease
Keywords: Aortic Valve Stenosis, Cardiac Surgical Procedures, Diagnostic Imaging, Geriatrics, Heart Valve Diseases, Outcome Assessment, Health Care, Phenotype, Secondary Prevention, Stroke Volume, Transcatheter Aortic Valve Replacement, Ventricular Function, Left
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