American heart journal · 2026
Clinical outcomes and impact of aortic valve replacement in concordant vs discordant high-gradient aortic stenosis.
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Sheashaa Hesham, Farina Juan M, Awad Kamal, Abbas Mohammed Tiseer, Pereyra Milagros, Scalia Isabel G, Abdelfattah Fatmaelzahraa, Ahmed Sherif, Razaghi Mahshad, Hafez Abdelrahman, Ibrahim Ramzi, Lester Steven J, Alsidawi Said, Fohtung Bamvi, Mital Rohit, Sell-Dottin Kristen, Ayoub Chadi, Arsanjani Reza
Аннотация
BACKGROUND: Data on clinical outcomes in patients with discordant high-gradient aortic stenosis (DHG-AS), defined by elevated gradients despite an aortic valve area (AVA) > 1 cm², remain conflicting. Limited information exists regarding the impact of aortic valve replacement (AVR) in DHG-AS.
METHODS: We analyzed patients with high-gradient aortic stenosis (mean gradient ≥ 40 mm Hg), categorized as concordant (AVA indexed to body surface area [AVAi] ≤ 0.6 cm²/m²) or discordant (AVAi > 0.6 cm²/m²). Propensity score matching (PSM) (1:1) adjusted for demographics and comorbidities. Kaplan-Meier curves and Cox proportional hazards models compared mortality and AVR rates between concordant high-gradient aortic stenosis (CHG-AS) and DHG-AS. For AVR, competing-risk methods used death as a competing event. In a subgroup of DHG-AS patients after PSM, Cox regression with AVR as a time-dependent covariate evaluated its association with mortality.
RESULTS: A total of 14,640 patients were included (13,678 CHG-AS; 962 DHG-AS). After PSM, 958 patients were in each group. DHG-AS had lower AVR rates (subdistribution HR [SHR] 0.56; 95% CI 0.50-0.63; Gray P < .001). Ten-year mortality was higher in DHG-AS in univariable analysis (HR 1.24; 95% CI 1.07-1.44; P = .005), but not after adjusting for AVR (HR 1.07; 95% CI 0.92-1.25). In DHG-AS patients after PSM (n = 360 per group), AVR reduced 10-year mortality (HR 0.538; 95% CI 0.418-0.692).
CONCLUSIONS: After accounting for AVR, survival did not differ significantly between DHG-AS and CHG-AS. AVR was associated with improved survival in DHG-AS, supporting timely intervention.
METHODS: We analyzed patients with high-gradient aortic stenosis (mean gradient ≥ 40 mm Hg), categorized as concordant (AVA indexed to body surface area [AVAi] ≤ 0.6 cm²/m²) or discordant (AVAi > 0.6 cm²/m²). Propensity score matching (PSM) (1:1) adjusted for demographics and comorbidities. Kaplan-Meier curves and Cox proportional hazards models compared mortality and AVR rates between concordant high-gradient aortic stenosis (CHG-AS) and DHG-AS. For AVR, competing-risk methods used death as a competing event. In a subgroup of DHG-AS patients after PSM, Cox regression with AVR as a time-dependent covariate evaluated its association with mortality.
RESULTS: A total of 14,640 patients were included (13,678 CHG-AS; 962 DHG-AS). After PSM, 958 patients were in each group. DHG-AS had lower AVR rates (subdistribution HR [SHR] 0.56; 95% CI 0.50-0.63; Gray P < .001). Ten-year mortality was higher in DHG-AS in univariable analysis (HR 1.24; 95% CI 1.07-1.44; P = .005), but not after adjusting for AVR (HR 1.07; 95% CI 0.92-1.25). In DHG-AS patients after PSM (n = 360 per group), AVR reduced 10-year mortality (HR 0.538; 95% CI 0.418-0.692).
CONCLUSIONS: After accounting for AVR, survival did not differ significantly between DHG-AS and CHG-AS. AVR was associated with improved survival in DHG-AS, supporting timely intervention.