Home > General Cardiology, Journal Club, Valvular heart disease > Journal Club 26 September 2012

Journal Club 26 September 2012


Outcome of Patients With Aortic Stenosis,
Small Valve Area, and Low-Flow, Low-Gradient Despite Preserved Left Ventricular Ejection Fraction


SP on behalf of AC



The aim of this case match study was to compare the outcome of patients with paradoxical low-flow (left ventricular
ejection fraction [LVEF] 50% but stroke volume index 35 ml/m2), low-gradient (mean gradient [MG]
40 mm Hg), a priori severe (aortic valve area [AVA] 1.0 cm2) aortic stenosis (AS) (PLG-SAS group) with that
of patients with a severe AS (AVA 1.0 cm2) and consistent high-gradient (MG 40 mm Hg) (HG-SAS group)
and with that of patients with a moderate AS (AVA 1.0 cm2 and MG 40 mm Hg) (MAS group).
Background In patients with preserved LVEF, a discordance between the AVA (in the severe range) and the gradient (in the
moderate range) raises uncertainty with regard to the actual severity of the stenosis and thus the therapeutic
management of the patient.


In a prospective cohort of AS patients with LVEF 50%, we identified 187 patients in the PLG-SAS group. These
patients were retrospectively matched: 1) according to the gradient, with 187 patients with MAS; and 2) according
to the AVA, with 187 patients with HG-SAS.


Patients with PLG-SAS had reduced overall survival (1-year: 89  2%; 5-year: 64  4%) compared with patients
with HG-SAS (1-year: 96  1%; 5-year: 82  3%) or MAS (1-year: 96  1%; 5-year: 81  3%). After adjustment
for other risk factors, patients with PLG-SAS had a 1.71-fold increase in overall mortality and a 2.09-fold increase
in cardiovascular mortality compared with the 2 other groups. Aortic valve replacement was significantly
associated with improved survival in the HG-SAS group (hazard ratio: 0.18; p  0.001) and in the PLG-SAS group
(hazard ratio: 0.50; p  0.04) but not in the MAS group.


Prognosis of patients with paradoxical low-flow, low-gradient severe AS was definitely worse than those with
high-gradient severe AS or those with moderate AS. The finding of a low gradient cannot exclude the presence of
a severe stenosis in a patient with a small AVA and preserved LVEF and should mandatorily prompt further

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