Doppler Mean Gradient Is Discordant to Aortic Valve Calcium Scores in Patients with Atrial Fibrillation Undergoing Transcatheter Aortic Valve Replacement

Adham K. Alkurashi, Sorin V. Pislaru, Jeremy J. Thaden, Jeremy D. Collins, Thomas Foley, Kevin L. Greason, Mackram F. Eleid, Gurpreet S. Sandhu, Mohamad A. Alkhouli, Samuel J. Asirvatham, Yong-Mei Cha, Eric E. Williamson, Juan A. Crestanello, Patricia A. Pellikka, Jae Kuen Oh, Vuyisile T. Nkomo

Research output: Contribution to journalArticlepeer-review

Abstract

Background: Doppler mean gradient (MG) may underestimate aortic stenosis (AS) severity when obtained during atrial fibrillation (AF) because of lower forward flow compared with sinus rhythm (SR). Whether AS is more advanced at the time of referral for aortic valve intervention in AF compared with SR is unknown. The aim of this study was to examine flow-independent computed tomographic aortic valve calcium scores (AVCS) and their concordance to MG in AF versus SR in patients undergoing transcatheter aortic valve replacement (TAVR). Methods: Patients who underwent TAVR from 2016 to 2020 for native valve severe AS with left ventricular ejection fraction ≥ 50% were identified from an institutional TAVR database. MGs during AF and SR in high-gradient AS (HGAS) and low-gradient AS (LGAS) were compared with AVCS (AVCS/MG ratio). AVCS were obtained within 90 days of pre-TAVR echocardiography. Results: Six hundred thirty-three patients were included; median age was 82 years (interquartile range [IQR], 76–86 years), and 46% were women. AF was present in 109 (17%) and SR in 524 (83%) patients during echocardiography. Aortic valve area index was slightly smaller in AF versus SR (0.43 cm2/m2 [IQR, 0.39–0.47 cm2/m2] vs 0.46 cm2/m2 [IQR, 0.41–0.51 cm2/m2], P = .0003). Stroke volume index, transaortic flow rate, and MG were lower in AF (P < .0001 for all). AVCS were higher in men with AF compared with SR (3,510 Agatston units [AU] [IQR, 2,803–4,030 AU] vs 2,722 AU [IQR, 2,180–3,467 AU], P < .0001) in HGAS but not in LGAS. AVCS were not different in women with AF versus SR. Overall AVCS/MG ratios were higher in AF versus SR in HGAS and LGAS (P < .03 for all), except in women with LGAS. Conclusions: AVCS were higher than expected by MG in AF compared with SR. The very high AVCS in men with AF and HGAS at the time of TAVR suggests late diagnosis of severe AS because of underestimated AS severity during progressive AS and/or late referral to TAVR. Additional studies are needed to examine the extent to which echocardiography may be underestimating AS severity in AF.

Original languageEnglish (US)
JournalJournal of the American Society of Echocardiography
DOIs
StateAccepted/In press - 2021

Keywords

  • Aortic stenosis
  • Aortic valve calcium score
  • Aortic valve replacement
  • Atrial fibrillation
  • Low flow
  • Transcatheter aortic valve replacement

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging
  • Cardiology and Cardiovascular Medicine

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