Progress in cardiovascular diseases · 2025
Clinical outcomes following TAVR for patients with low and very low gradient aortic stenosis.
СтатьяСравнительное исследованиеНазвание и аннотация: Перевод пока не подготовлен
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Besir Besir, Lomaia Tamari, Ramu Shivabalan Kathavarayan, Rajendran Judah, Reed Grant W, Puri Rishi, Harb Serge C, Popovic Zoran, Krishnaswamy Amar, Kapadia Samir R
Аннотация
OBJECTIVES: This study explores the impact of lower baseline aortic valve (AV) mean gradients on the clinical outcomes of patients with low-gradient aortic stenosis (LG AS) post-transcatheter aortic valve replacement (TAVR). Additionally, the study aims to understand the predictors of a lower baseline AV mean gradient (MG).
BACKGROUND: Reduced left ventricular ejection fraction (LVEF) and low-flow states are known to correlate with worse clinical outcomes. Lower mean gradients are also known to correlate with poorer outcomes, but the outcomes of patients with very low-gradient AS compared to low-gradient AS are not well understood.
METHODS: This is a retrospective cohort of patients >18 years who underwent TAVR at Cleveland Clinic between 2016 and 2020. Only patients with AV area < 1 cm2, and AV MG <40 mmHg were included. Patients who underwent valve-in-valve TAVR were excluded. Patients were classified into 3 tertiles according to their baseline AV MG. Clinical outcomes included mortality and heart failure hospitalization. Survival analysis was used to assess the clinical outcomes between the tertiles.
RESULTS: Around 60 % of the patients in this study were males, with a mean age of 80 years. The mean AV MG was 21.8 ± 4.0 mmHg for the first tertile, 30.9 ± 1.9 mmHg for the second tertile, and 37.1 ± 1.6 mmHg for the third tertile. The present study shows that patients with very low-gradient AS (first tertile) have higher mortality rates compared to those with low-gradient AS (third tertile) (hazard ratio: 2.07, 95 % confidence interval (1.2-3.6)), even after stratifying by flow and by LVEF. Lower stroke volume index (SVI), lower LVEF, atrial fibrillation, and moderate to severe TR were associated with lower mean gradients.
CONCLUSIONS: Patients with very low-gradient AS have worse outcomes than those with low-gradient AS. Multiple clinical characteristics, including a lower SVI, lower LVEF, and atrial fibrillation, correlate with having very low-gradient AS. Therefore patients with low-gradient AS should undergo earlier intervention to improve their clinical outcomes.
BACKGROUND: Reduced left ventricular ejection fraction (LVEF) and low-flow states are known to correlate with worse clinical outcomes. Lower mean gradients are also known to correlate with poorer outcomes, but the outcomes of patients with very low-gradient AS compared to low-gradient AS are not well understood.
METHODS: This is a retrospective cohort of patients >18 years who underwent TAVR at Cleveland Clinic between 2016 and 2020. Only patients with AV area < 1 cm2, and AV MG <40 mmHg were included. Patients who underwent valve-in-valve TAVR were excluded. Patients were classified into 3 tertiles according to their baseline AV MG. Clinical outcomes included mortality and heart failure hospitalization. Survival analysis was used to assess the clinical outcomes between the tertiles.
RESULTS: Around 60 % of the patients in this study were males, with a mean age of 80 years. The mean AV MG was 21.8 ± 4.0 mmHg for the first tertile, 30.9 ± 1.9 mmHg for the second tertile, and 37.1 ± 1.6 mmHg for the third tertile. The present study shows that patients with very low-gradient AS (first tertile) have higher mortality rates compared to those with low-gradient AS (third tertile) (hazard ratio: 2.07, 95 % confidence interval (1.2-3.6)), even after stratifying by flow and by LVEF. Lower stroke volume index (SVI), lower LVEF, atrial fibrillation, and moderate to severe TR were associated with lower mean gradients.
CONCLUSIONS: Patients with very low-gradient AS have worse outcomes than those with low-gradient AS. Multiple clinical characteristics, including a lower SVI, lower LVEF, and atrial fibrillation, correlate with having very low-gradient AS. Therefore patients with low-gradient AS should undergo earlier intervention to improve their clinical outcomes.