PLF-LG AS patients had worse right ventricular function and highest 5-year cardiovascular mortality compared to LF-HG and NF-HG AS despite preserved LVEF.
Does the paradoxical low-flow low-gradient AS phenotype worsen cardiovascular and all-cause mortality compared to high-gradient AS phenotypes in patients with severe AS and preserved LVEF undergoing TAVR?
In patients with severe AS and preserved LVEF undergoing TAVR, the paradoxical low-flow low-gradient phenotype is associated with worse right ventricular function and higher 5-year cardiovascular mortality compared to high-gradient phenotypes.
Absolute Event Rate: 0% vs 0%
Abstract Background In patients with severe aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF) both high-gradient (HG) and low-gradient (LG) constellations can be associated with a reduced LV stroke volume index (SVi 35mL/m2). While the prognostic significance of a reduced SVi in paradoxical low-flow, low-gradient AS (PLF-LG AS) is well established, data on the clinical characteristics and outcomes of patients with reduced SVi in HG AS remain scarce. Methods The study included 184 patients with severe AS and preserved LVEF who underwent transcatheter aortic valve replacement (TAVR). Three groups were categorized: (1) Low-flow high-gradient AS (LF-HG AS): LVEF 50%, Vmax ≥4 m/s, Pmean ≥40 mmHg, SVI ≤35 mL/m2, AVA ≤1.0 cm2 (2) Normal-flow high-gradient AS (NF-HG AS): LVEF 50%, Vmax ≥4 m/s, Pmean ≥40 mmHg, SVI35 mL/m2, AVA ≤1.0 cm2 (3) Paradoxical low-flow low-gradient AS (PLF-LG AS): LVEF 50%, Vmax 4 m/s, Pmean 40 mmHg, AVA ≤1.0 cm2, SVI ≤35 mL/m2 Patients were comprehensively analyzed using a multimodal approach, including clinical data, echocardiography, cardiac magnetic resonance (CMR) imaging, multidetector computed tomography, histology and next-generation sequencing (NGS). Cardiovascular and all-cause mortality were defined as primary clinical endpoints. Results While there were no relevant differences in baseline characteristics between LF-HG and NF-HG subgroups, PLF- LG AS patients demonstrated greater symptom burden of heart failure compared to HG subgroups (NT-proBNP: LF-HG: 2328 ± 3370 ng/L; NF-HG: 1623±2398 ng/L; PLF-LG: 2150±1579 ng/L; p=0.007; Minnesota Living with Heart Failure Questionnaire: LF-HG: 32.6±16.5; NF-HG: 27.8±17.7; PLF-LG: 36.8±16.4; p=0.01). Echocardiography and CMR imaging revealed impaired right ventricular (RV) function in PLF-LG AS patients compared to HG subgroups (TAPSE: LF-HG: 21.4±4.1 mm; NF-HG: 23.2±4.3 mm; PLF-LG: 19.4±4.3 mm; p=0.01; RVEF: LF-HG: 56.9% (47.8;61.4%); NF-HG: 57.6% (53.1;63.5%) PLF-LG: 49.3% (42.8;58.8%); p=0.027; RV GLS: LF-HG: -27.8% (- 21.3;-31.6%); NF-HG: -31.1% (-25.6;-35.3%); PLF-LG: -25.8% (-22.3;-28.8%); p=0.007). Assessing myocardial fibrosis, there were no significant differences among all three groups neither in histological analyses (LF-HG: 12.3±14.3 %; NF-HG: 14.7±13.7 %; PLF-LG: 16.8±13.7 %; p=0.55) nor in CMR-derived extracellular volume (LF-HG: 24.5% (23.2;25.9%); NF-HG: 25.5 (24.0;26.9%); PLF-LG: 26.6% (24.1;28.0%); p=0.26). Among all subgroups, PLF-LG AS patients had the highest 5-year cardiovascular mortality (Figure 1). Conclusion Among AS patients with preserved LVEF, LF-HG and NF-HG had similar clinical profiles and outcomes, indicating a comparable disease course. In contrast, PLF-LG showed more severe right-sided heart failure and the worst long-term prognosis. Thus, reduced SVi may not be a useful marker for risk stratification or patient management in LF-HG AS.
Gersch et al. (Sat,) reported a other. PLF-LG AS patients had worse right ventricular function and highest 5-year cardiovascular mortality compared to LF-HG and NF-HG AS despite preserved LVEF.