Outcomes of Transcatheter Aortic Valve Replacement Patients With Different Transvalvular Flow-gradient Patterns

• Published in: The American journal of cardiology Vol. 209; pp. 173 - 180
• Main Authors: Muratori, Manuela, Fusini, Laura, Tamborini, Gloria, Gripari, Paola, Ali, Sarah Ghulam, Mantegazza, Valentina, Garlasche, Anna, Fabbiocchi, Franco, Agrifoglio, Marco, Bartorelli, Antonio L., Pontone, Gianluca, Pepi, Mauro
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 15.12.2023; Elsevier Limited
• Subjects: Aorta; Aortic stenosis; Aortic valve; Aortic Valve - diagnostic imaging; Aortic Valve - surgery; Aortic Valve Stenosis; Cardiac arrhythmia; echocardiography; Heart; Heart valves; Hemodynamics; Humans; Hypertrophy; Low flow; low-flow low-gradient; Mortality; Mortality risk; paradoxical low-flow low-gradient; Patients; Severity of Illness Index; Stroke Volume; Survival; TAVR; Transcatheter Aortic Valve Replacement - methods; Treatment Outcome; Velocity; Ventricle; Ventricular Function, Left; United States > US; Minnesota; aortic stenosis; low-flow low-gradient; paradoxical low-flow low-gradient; TAVR; echocardiography
• ISSN: 0002-9149; 1879-1913; 1879-1913
• DOI: 10.1016/j.amjcard.2023.09.095

Low-flow low-gradient (LF-LG) aortic stenosis (AS) may occur with preserved or depressed left ventricular ejection fraction (LVEF). Both situations represent the most challenging subset of patients to manage and generally have a poor prognosis. Few and controversial data exist on the outcomes of these patients compared to normal-flow high-gradient (NF-HG) AS following transcatheter aortic valve replacement (TAVR). We sought to characterize different transvalvular flow-gradient patterns and to examine their prognostic value after TAVR. We enrolled 1208 patients with severe AS and categorized as follow: 976 patients NF-HG (mean aortic pressure gradient, MPG≥40mmHg), 107 paradoxical cLF-LG (pLF-LG, MPG<40mmHg, LVEF≥50%, stroke volume index, SVi<35mL/m2), and 125 cLF-LG (MPG<40mmHg, LVEF<50%, SVi<35mL/m2). When compared with NF-HG and pLF-LG, cLF-LG had a worse symptomatic status (NYHA III-IV 86% vs 62% and 67%, p<0.001), a higher prevalence of eccentric hypertrophy and a higher level of LV global afterload reflected by a higher valvuloarterial impedance. Valvular function after TAVR was excellent over time in all patients. While 30-day mortality (p=0.911) did not differ significantly among groups, cLF-LG had a lower 5-year survival rate (LF-LG 50% vs pLF-LG 62% and NF-HG 68%, p<0.05). cLF-LG was associated with a hazard ratio for mortality of 2.41 (95% CI: 1.65-3.52, p<0.001). In conclusion, TAVR is an effective procedure regardless of transvalvular flow-gradient patterns. However, special care should be given to characterized hemodynamic of AS, as patients with pLF-LG had similar survival rates than patients with NF-HG, whereas cLF-LG is associated with a 2-fold increased risk of mortality at 5-year follow-up.