Risk prediction in patients with classical low-flow, low-gradient aortic stenosis undergoing surgical intervention

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Tessari, Fernanda Castiglioni ; Lopes, Maria Antonieta Albanez A. de M. ; Campos, Carlos M. M. ; Rosa, Vitor Emer Egypto ; Sampaio, Roney Orismar ; Soares, Frederico Jose Mendes Mendonca ; Lopes, Rener Romulo Souza ; Nazzetta, Daniella Cian ; de Brito Jr, Fabio Sandoli ; Ribeiro, Henrique Barbosa ; Vieira, Marcelo L. C. ; Mathias Jr, Wilson ; Fernandes, Joao Ricardo Cordeiro ; Lopes, Mariana Pezzute ; Rochitte, Carlos E. E. ; Pomerantzeff, Pablo M. A. ; Abizaid, Alexandre ; Tarasoutchi, Flavio

• Document type: Journal article
• Source: FRONTIERS IN CARDIOVASCULAR MEDICINE; v. 10, p. 9-pg., 2023-06-12.

Abstract

IntroductionClassical low-flow, low-gradient aortic stenosis (LFLG-AS) is an advanced stage of aortic stenosis, which has a poor prognosis with medical treatment and a high operative mortality after surgical aortic valve replacement (SAVR). There is currently a paucity of information regarding the current prognosis of classical LFLG-AS patients undergoing SAVR and the lack of a reliable risk assessment tool for this particular subset of AS patients. The present study aims to assess mortality predictors in a population of classical LFLG-AS patients undergoing SAVR.MethodsThis is a prospective study including 41 consecutive classical LFLG-AS patients (aortic valve area & LE;1.0 cm(2), mean transaortic gradient <40 mmHg, left ventricular ejection fraction <50%). All patients underwent dobutamine stress echocardiography (DSE), 3D echocardiography, and T1 mapping cardiac magnetic resonance (CMR). Patients with pseudo-severe aortic stenosis were excluded. Patients were divided into groups according to the median value of the mean transaortic gradient (& LE;25 and >25 mmHg). All-cause, intraprocedural, 30-day, and 1-year mortality rates were evaluated.ResultsAll of the patients had degenerative aortic stenosis, with a median age of 66 (60-73) years; most of the patients were men (83%). The median EuroSCORE II was 2.19% (1.5%-4.78%), and the median STS was 2.19% (1.6%-3.99%). On DSE, 73.2% had flow reserve (FR), i.e., an increase in stroke volume & GE;20% during DSE, with no significant differences between groups. On CMR, late gadolinium enhancement mass was lower in the group with mean transaortic gradient >25 mmHg [2.0 (0.0-8.9) g vs. 8.5 (2.3-15.0) g; p = 0.034), and myocardium extracellular volume (ECV) and indexed ECV were similar between groups. The 30-day and 1-year mortality rates were 14.6% and 43.8%, respectively. The median follow-up was 4.1 (0.3-5.1) years. By multivariate analysis adjusted for FR, only the mean transaortic gradient was an independent predictor of mortality (hazard ratio: 0.923, 95% confidence interval: 0.864-0.986, p = 0.019). A mean transaortic gradient & LE;25 mmHg was associated with higher all-cause mortality rates (log-rank p = 0.038), while there was no difference in mortality regarding FR status (log-rank p = 0.114).ConclusionsIn patients with classical LFLG-AS undergoing SAVR, the mean transaortic gradient was the only independent mortality predictor in patients with LFLG-AS, especially if & LE;25 mmHg. The absence of left ventricular FR had no prognostic impact on long-term outcomes. (AU)

• FAPESP's process: 13/06149-6 - Contribution of tridimensional echocardiography and cardiovascular magnetic resonance imaging (T1 mapping) for low-flow low-gradient aortic stenosis
• Grantee: Roney Orismar Sampaio
• Support Opportunities: Regular Research Grants