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Comment
. 2023 Jan 15:371:299-304.
doi: 10.1016/j.ijcard.2022.10.143. Epub 2022 Oct 25.

TAVI for patients with normal-flow low-gradient compared to high-gradient aortic stenosis

Julius Steffen  1 , David Andreae  2 , Michael Nabauer  2 , Nikolas Reißig  2 , Philipp M Doldi  1 , Magda Haum  2 , Martin Orban  2 , Hans Theiss  2 , Konstantinos Rizas  1 , Daniel Braun  2 , Sven Peterß  3 , Jörg Hausleiter  1 , Steffen Massberg  1 , Simon Deseive  4
Affiliations
Comment

TAVI for patients with normal-flow low-gradient compared to high-gradient aortic stenosis

Julius Steffen et al. Int J Cardiol. .

Abstract

Background: Normal-flow (stroke volume index, SVi >35 ml/m2) low-gradient (dPmean <40 mmHg) aortic stenosis (NFLG-AS) is subject of scientific debate. Guidelines fail to give conclusive treatment recommendations. We hypothesized that NFLG patients are heterogenous, containing a subgroup similar to high-gradient aortic stenosis patients (dPmean ≥40 mmHg, HG-AS) concerning characteristics and outcomes.

Methods: 2326 patients undergoing transcatheter aortic valve replacement (TAVI) at our centre between 2013 and 2019 were analysed. 386 patients fulfilled criteria of NFLG-AS. Their median dPmean was 33 mmHg, which was used for grouping (204 patients with higher gradient NFLG-AS, 186 patients with lower gradient NFLG-AS). They were compared to 956 HG-AS patients.

Results: Characteristics of lower gradient NFLG-AS patients differed from HG-AS patients in many aspects while higher gradient NFLG-AS and HG-AS patients were mostly similar, underscored by higher Society of Thoracic Surgeons scores in lower gradient NFLG-AS (lower gradient NFLG-AS, 3.9, HG-AS, 3.0, p = 0.03, higher gradient NFLG-AS, 3.0, p = 0.04). Procedural complications were comparable. Estimated 3-year all-cause mortality was higher in lower gradient NFLG-AS compared to HG-AS patients (hazard ratio 1.7, p < 0.01), whereas mortality of higher gradient NFLG-AS was similar to HG-AS patients (hazard ratio 1.2, p = 0.31). Cardiovascular mortality was highest among lower gradient NFLG-AS patients (21.6% vs. higher gradient NFLG-AS, 15.4%, vs. HG-AS, 11.1%, p < 0.01).

Conclusions: NFLG-AS patients are indeed heterogenous. NFLG-AS patients with higher gradients resemble HG-AS patients in clinical characteristics and outcomes and should not be treated differently. Lower gradient NFLG-AS patients have increased long-term mortality and the use of TAVI requires careful consideration.

Keywords: Aortic stenosis; Low-flow low-gradient; Normal-flow low-gradient; TAVI; VARC-3.

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Conflict of interest statement

Conflicts of interest JS received speaker honoraria from AstraZeneca. MO received speaker honoraria and travel compensations from Abbott Medical, AstraZeneca, Abiomed, Bayer vital, BIOTRONIK, Bristol-Myers Squibb, CytoSorbents, Daiichi Sankyo Germany, Edwards Lifesciences Services, and Sedana Medical. JH received research support Abbott Vascular and Edwards Lifesciences. DB received speaker honoraria from Abbott Vascular. SD received speaker honoraria from AstraZeneca. The other authors report no conflict of interest.

Comment on

  • Low-gradient aortic stenosis.
    Clavel MA, Magne J, Pibarot P. Clavel MA, et al. Eur Heart J. 2016 Sep 7;37(34):2645-57. doi: 10.1093/eurheartj/ehw096. Epub 2016 Mar 31. Eur Heart J. 2016. PMID: 27190103 Free PMC article. Review.

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