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Comparative Study
. 2021 Jun;8(1):e001639.
doi: 10.1136/openhrt-2021-001639.

Discordant severity criteria in patients with moderate aortic stenosis: prognostic implications

Stephan M Pio #  1 , Mohammed R Amanullah #  2 , Steele C Butcher  1   3 , Kenny Y Sin  4 , Nina Ajmone Marsan  1 , Philippe Pibarot  5 , Nicolas M Van Mieghem  6 , Zee Pin Ding  2 , Philippe Généreux  7 , Martin B Leon  8 , See Hooi Ewe  2 , Victoria Delgado  1 , Jeroen J Bax  9
Affiliations
Comparative Study

Discordant severity criteria in patients with moderate aortic stenosis: prognostic implications

Stephan M Pio et al. Open Heart. 2021 Jun.

Abstract

Background: The criteria to define the grade of aortic stenosis (AS)-aortic valve area (AVA) and mean gradient (MG) or peak jet velocity-do not always coincide into one grade. Although in severe AS, this discrepancy is well characterised, in moderate AS, the phenomenon of discordant grading has not been investigated and its prognostic implications are unknown.

Objectives: To investigate the occurrence of discordant grading in patients with moderate AS (defined by an AVA between 1.0 cm² and 1.5 cm² but with an MG <20 mm Hg) and how these patients compare with those with concordant grading moderate AS (AVA between 1.0 cm² and 1.5 cm² and MG ≥20 mm Hg) in terms of clinical outcomes.

Methods: From an ongoing registry of patients with AS, patients with moderate AS based on AVA were selected and classified into discordant or concordant grading (MG <20 mm Hg or ≥20 mm Hg, respectively). The clinical endpoint was all-cause mortality.

Results: Of 790 patients with moderate AS, 150 (19.0%) had discordant grading, moderate AS. Patients with discordant grading were older, had higher prevalence of previous myocardial infarction and left ventricular (LV) hypertrophy, larger LV end-diastolic and end-systolic volume index, higher LV filling pressure and lower LV ejection fraction and stroke volume index as compared with their counterparts. After a median follow-up of 4.9 years (IQR 3.0-8.2), patients with discordant grading had lower aortic valve replacement rates (26.7% vs 44.1%, p<0.001) and higher mortality rates (60.0% vs 43.1%, p<0.001) as compared with patients with concordant grading. Discordant grading moderate AS, combined with low LV ejection fraction, presented the higher risk of mortality (HR 2.78 (2.00-3.87), p<0.001).

Conclusion: Discordant-grading moderate AS is not uncommon and, when combined with low LV ejection fraction, is associated with high risk of mortality.

Keywords: aortic valve stenosis; diagnostic imaging; echocardiography.

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Conflict of interest statement

Competing interests: The Department of Cardiology, Heart Lung Center, Leiden University Medical Center has received grants from Biotronik, Medtronic, Boston Scientific, GE Healthcare, and Edwards Lifesciences. NAM has received speaker fees from Abbott and Philips Ultrasound. ZPD has received speaker fees from Philips. PP has received grant support from Edwards Lifesciences and Medtronic. SHE has received speaker fees from Edwards Lifesciences and Abbott Vascular. VD has received speaker fees from Abbott Vascular. JJB has received speaker fees from Abbott Vascular and Boehringer Ingelheim. PG reports speaker fee from Edwards Lifesciences, Cordis, Medtronic; Consultant: Abiomed, Boston Scientific, Cardiovascular System Inc., Cordis, Edwards Lifesciences, Medtronic, Opsens, Soundbite Medical Solutions Inc., Pi-Cardia, Saranas, Siemens, Shockwave Medical Inc., SIG.NUM; Teleflex, 4C Medical, Shareholder: Soundbite Medical Solutions Inc., SIG.NUM, Pi-Cardia, Puzzle Medical. MBL is an early physician founder of Mitralign and has an equity relationship (< 1% of the company).

Figures

Figure 1
Figure 1
Classification of patients with moderate aortic stenosis according to concordance of mean gradient with aortic valve area. Discordant grading, moderate aortic stenosis has a considerable prevalence (19%).
Figure 2
Figure 2
Echocardiographic differences between patients with discordant vs concordant grading. Patients with discordant grading, moderate AS significantly lower SVi and LVEF values compared with patients with concordant grading moderate AS. AS, aortic stenosis; AVA, aortic valve area; LVEF, left ventricular ejection fraction; SVi, stroke volume index.
Figure 3
Figure 3
Kaplan-Meier estimates of all-cause mortality according to gradient concordance and LVEF. LVEF, left ventricular ejection fraction.
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Comment in

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