Flow-gradient patterns in severe aortic stenosis with preserved ejection fraction: Clinical characteristics and predictors of survival

Mackram Eleid, Paul Sorajja, Hector I Michelena, Joseph F. Malouf, Christopher G. Scott, Patricia Pellikka

Research output: Contribution to journalArticle

155 Citations (Scopus)

Abstract

BACKGROUND-: Among patients with severe aortic stenosis (AS) and preserved ejection fraction, those with low gradient (LG) and reduced stroke volume may have an adverse prognosis. We investigated the prognostic impact of stroke volume using the recently proposed flow-gradient classification. METHODS AND RESULTS-: We examined 1704 consecutive patients with severe AS (aortic valve area <1.0 cm) and preserved ejection fraction (≥50%) using 2-dimensional and Doppler echocardiography. Patients were stratified by stroke volume index (<35 mL/m [low flow, LF] versus ≥35 mL/m [normal flow, NF]) and aortic gradient (<40 mm Hg [LG] versus ≥40 mm Hg [high gradient, HG]) into 4 groups: NF/HG, NF/LG, LF/HG, and LF/LG. NF/LG (n=352, 21%), was associated with favorable survival with medical management (2-year estimate, 82% versus 67% in NF/HG; P<0.0001). LF/LG severe AS (n=53, 3%) was characterized by lower ejection fraction, more prevalent atrial fibrillation and heart failure, reduced arterial compliance, and reduced survival (2-year estimate, 60% versus 82% in NF/HG; P<0.001). In multivariable analysis, the LF/LG pattern was the strongest predictor of mortality (hazard ratio, 3.26; 95% confidence interval, 1.71-6.22; P<0.001 versus NF/LG). Aortic valve replacement was associated with a 69% mortality reduction (hazard ratio, 0.31; 95% confidence interval, 0.25-0.39; P<0.0001) in LF/LG and NF/HG, with no survival benefit associated with aortic valve replacement in NF/LG and LF/HG. CONCLUSIONS-: NF/LG severe AS with preserved ejection fraction exhibits favorable survival with medical management, and the impact of aortic valve replacement on survival was neutral. LF/LG severe AS is characterized by a high prevalence of atrial fibrillation, heart failure, and reduced survival, and aortic valve replacement was associated with improved survival. These findings have implications for the evaluation and subsequent management of AS severity.

Original languageEnglish (US)
Pages (from-to)1781-1789
Number of pages9
JournalCirculation
Volume128
Issue number16
DOIs
StatePublished - Oct 15 2013

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Aortic Valve Stenosis
Aortic Valve
Survival
Stroke Volume
Atrial Fibrillation
Heart Failure
Confidence Intervals
Mortality
Doppler Echocardiography
Compliance

Keywords

  • echocardiography
  • heart valves
  • surgery
  • survival
  • valves

ASJC Scopus subject areas

  • Physiology (medical)
  • Cardiology and Cardiovascular Medicine

Cite this

Flow-gradient patterns in severe aortic stenosis with preserved ejection fraction : Clinical characteristics and predictors of survival. / Eleid, Mackram; Sorajja, Paul; Michelena, Hector I; Malouf, Joseph F.; Scott, Christopher G.; Pellikka, Patricia.

In: Circulation, Vol. 128, No. 16, 15.10.2013, p. 1781-1789.

Research output: Contribution to journalArticle

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title = "Flow-gradient patterns in severe aortic stenosis with preserved ejection fraction: Clinical characteristics and predictors of survival",
abstract = "BACKGROUND-: Among patients with severe aortic stenosis (AS) and preserved ejection fraction, those with low gradient (LG) and reduced stroke volume may have an adverse prognosis. We investigated the prognostic impact of stroke volume using the recently proposed flow-gradient classification. METHODS AND RESULTS-: We examined 1704 consecutive patients with severe AS (aortic valve area <1.0 cm) and preserved ejection fraction (≥50{\%}) using 2-dimensional and Doppler echocardiography. Patients were stratified by stroke volume index (<35 mL/m [low flow, LF] versus ≥35 mL/m [normal flow, NF]) and aortic gradient (<40 mm Hg [LG] versus ≥40 mm Hg [high gradient, HG]) into 4 groups: NF/HG, NF/LG, LF/HG, and LF/LG. NF/LG (n=352, 21{\%}), was associated with favorable survival with medical management (2-year estimate, 82{\%} versus 67{\%} in NF/HG; P<0.0001). LF/LG severe AS (n=53, 3{\%}) was characterized by lower ejection fraction, more prevalent atrial fibrillation and heart failure, reduced arterial compliance, and reduced survival (2-year estimate, 60{\%} versus 82{\%} in NF/HG; P<0.001). In multivariable analysis, the LF/LG pattern was the strongest predictor of mortality (hazard ratio, 3.26; 95{\%} confidence interval, 1.71-6.22; P<0.001 versus NF/LG). Aortic valve replacement was associated with a 69{\%} mortality reduction (hazard ratio, 0.31; 95{\%} confidence interval, 0.25-0.39; P<0.0001) in LF/LG and NF/HG, with no survival benefit associated with aortic valve replacement in NF/LG and LF/HG. CONCLUSIONS-: NF/LG severe AS with preserved ejection fraction exhibits favorable survival with medical management, and the impact of aortic valve replacement on survival was neutral. LF/LG severe AS is characterized by a high prevalence of atrial fibrillation, heart failure, and reduced survival, and aortic valve replacement was associated with improved survival. These findings have implications for the evaluation and subsequent management of AS severity.",
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T1 - Flow-gradient patterns in severe aortic stenosis with preserved ejection fraction

T2 - Clinical characteristics and predictors of survival

AU - Eleid, Mackram

AU - Sorajja, Paul

AU - Michelena, Hector I

AU - Malouf, Joseph F.

AU - Scott, Christopher G.

AU - Pellikka, Patricia

PY - 2013/10/15

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N2 - BACKGROUND-: Among patients with severe aortic stenosis (AS) and preserved ejection fraction, those with low gradient (LG) and reduced stroke volume may have an adverse prognosis. We investigated the prognostic impact of stroke volume using the recently proposed flow-gradient classification. METHODS AND RESULTS-: We examined 1704 consecutive patients with severe AS (aortic valve area <1.0 cm) and preserved ejection fraction (≥50%) using 2-dimensional and Doppler echocardiography. Patients were stratified by stroke volume index (<35 mL/m [low flow, LF] versus ≥35 mL/m [normal flow, NF]) and aortic gradient (<40 mm Hg [LG] versus ≥40 mm Hg [high gradient, HG]) into 4 groups: NF/HG, NF/LG, LF/HG, and LF/LG. NF/LG (n=352, 21%), was associated with favorable survival with medical management (2-year estimate, 82% versus 67% in NF/HG; P<0.0001). LF/LG severe AS (n=53, 3%) was characterized by lower ejection fraction, more prevalent atrial fibrillation and heart failure, reduced arterial compliance, and reduced survival (2-year estimate, 60% versus 82% in NF/HG; P<0.001). In multivariable analysis, the LF/LG pattern was the strongest predictor of mortality (hazard ratio, 3.26; 95% confidence interval, 1.71-6.22; P<0.001 versus NF/LG). Aortic valve replacement was associated with a 69% mortality reduction (hazard ratio, 0.31; 95% confidence interval, 0.25-0.39; P<0.0001) in LF/LG and NF/HG, with no survival benefit associated with aortic valve replacement in NF/LG and LF/HG. CONCLUSIONS-: NF/LG severe AS with preserved ejection fraction exhibits favorable survival with medical management, and the impact of aortic valve replacement on survival was neutral. LF/LG severe AS is characterized by a high prevalence of atrial fibrillation, heart failure, and reduced survival, and aortic valve replacement was associated with improved survival. These findings have implications for the evaluation and subsequent management of AS severity.

AB - BACKGROUND-: Among patients with severe aortic stenosis (AS) and preserved ejection fraction, those with low gradient (LG) and reduced stroke volume may have an adverse prognosis. We investigated the prognostic impact of stroke volume using the recently proposed flow-gradient classification. METHODS AND RESULTS-: We examined 1704 consecutive patients with severe AS (aortic valve area <1.0 cm) and preserved ejection fraction (≥50%) using 2-dimensional and Doppler echocardiography. Patients were stratified by stroke volume index (<35 mL/m [low flow, LF] versus ≥35 mL/m [normal flow, NF]) and aortic gradient (<40 mm Hg [LG] versus ≥40 mm Hg [high gradient, HG]) into 4 groups: NF/HG, NF/LG, LF/HG, and LF/LG. NF/LG (n=352, 21%), was associated with favorable survival with medical management (2-year estimate, 82% versus 67% in NF/HG; P<0.0001). LF/LG severe AS (n=53, 3%) was characterized by lower ejection fraction, more prevalent atrial fibrillation and heart failure, reduced arterial compliance, and reduced survival (2-year estimate, 60% versus 82% in NF/HG; P<0.001). In multivariable analysis, the LF/LG pattern was the strongest predictor of mortality (hazard ratio, 3.26; 95% confidence interval, 1.71-6.22; P<0.001 versus NF/LG). Aortic valve replacement was associated with a 69% mortality reduction (hazard ratio, 0.31; 95% confidence interval, 0.25-0.39; P<0.0001) in LF/LG and NF/HG, with no survival benefit associated with aortic valve replacement in NF/LG and LF/HG. CONCLUSIONS-: NF/LG severe AS with preserved ejection fraction exhibits favorable survival with medical management, and the impact of aortic valve replacement on survival was neutral. LF/LG severe AS is characterized by a high prevalence of atrial fibrillation, heart failure, and reduced survival, and aortic valve replacement was associated with improved survival. These findings have implications for the evaluation and subsequent management of AS severity.

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KW - heart valves

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