Outcome and Impact of Surgery in Paradoxical Low-Flow, Low-Gradient Severe Aortic Stenosis and Preserved Left Ventricular Ejection Fraction

• Published in: Circulation (New York, N.Y.) Vol. 128; no. 11_suppl_1; pp. S235 - 42
• Main Authors: Mohty, Dania, Magne, Julien, Deltreuil, Mathieu, Aboyans, Victor, Echahidi, Najmeddine, Cassat, Claude, Pibarot, Philippe, Laskar, Marc, Virot, Patrice
• Format: Journal Article
• Language: English
• Published: American Heart Association 10.09.2013
• Subjects: Aged; Aged, 80 and over; Aortic Valve Stenosis; Blood Flow Velocity; Cardiac Catheterization; Cohort Studies; Female; Follow-Up Studies; Humans; Life Sciences; Male; Retrospective Studies; Santé publique et épidémiologie; Severity of Illness Index; Stroke Volume; Survival Rate; Treatment Outcome; Ventricular Function, Left; LV function; catheterization; aortic stenosis; valve; survival; surgery
• ISSN: 0009-7322; 1524-4539
• DOI: 10.1161/CIRCULATIONAHA.112.000031

Background— The clinical relevance and management of paradoxical low-flow, low-gradient aortic stenosis (LFLG-AS) with preserved left ventricular ejection fraction remain debated. The aim of this study is to determine the features and outcome of LFLG-AS assessed using cardiac catheterization. Methods and Results— Between 2000 and 2010, 768 patients with preserved left ventricular ejection fraction (>50%) and severe AS (valve area ≤1cm 2 ) without other valvular disease underwent cardiac catheterization. Mean age was 74±8 years, 42% were women, and 46% had associated coronary artery disease. The prevalence of LFLG (indexed left ventricular stroke volume <35 mL/m 2 and mean gradient <40 mm Hg), normal flow high gradient, normal flow low gradient, and low flow high gradient were 13%, 50%, 22%, and 15%, respectively. Compared with patients with normal flow high gradient, those with LFLG were significantly older, with significantly reduced systemic arterial compliance and vascular resistances and increased valvulo-arterial impedance (all P <0.05). Ten-year survival was reduced in LFLG-AS (32±9%) compared with normal flow high gradient (66±4%; P =0.0002). After adjustment for other risk factors, LFLG-AS was independently associated with reduced long-term survival (hazard ratio, 1.85; 95% confidence interval, 1.08–3.07; P =0.02). However, despite higher operative mortality, patients with LFLG-AS undergoing aortic valve replacement seemed to have better long-term survival than those managed conservatively (5-year survival rate: 63±6% versus 38±15%; P =0.007; hazard ratio, 0.23; 95% confidence interval, 0.09–0.59; P =0.002). Conclusions— This large cardiac catheterization–based study reports that the LFLG-AS entity is not rare and is associated with worse outcome whether treated medically or surgically. However, these patients may have better long-term survival if treated surgically. Further prospective studies are needed to confirm this finding.