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Discordant criteria in moderate aortic stenosis patients: prognostic implications

Session Poster Session 4

Speaker Stephan Milhorini Pio

Event : ESC Congress 2019

  • Topic : valvular, myocardial, pericardial, pulmonary, congenital heart disease
  • Sub-topic : Diagnostic Methods
  • Session type : Poster Session

Authors : S M Pio (Leiden,NL), MR Amanullah (Singapore,SG), KY Sin (Singapore,SG), N Ajmone Marsan (Leiden,NL), ZP Ding (Singapore,SG), SH Ewe (Singapore,SG), V Delgado (Leiden,NL), JJ Bax (Leiden,NL)

Authors:
S.M. Pio1 , M.R. Amanullah2 , K.Y. Sin3 , N. Ajmone Marsan1 , Z.P. Ding2 , S.H. Ewe2 , V. Delgado1 , J.J. Bax1 , 1Leiden University Medical Center - Leiden - Netherlands (The) , 2National Heart Centre Singapore, Department of Cardiology - Singapore - Singapore , 3National Heart Centre Singapore, Department of Cardiothoracic Surgery - Singapore - Singapore ,

Topic(s):
Valvular Heart Disease – Diagnostic Methods

Citation:
European Heart Journal ( 2019 ) 40 ( Supplement ), 2294

Background: The frequency of discordant mean valve gradient (MG) and aortic valve area (AVA) in patients with moderate aortic stenosis (AS) has not been investigated.

Objectives: Determine the occurrence of discordant gradient in patients with moderate AS (defined by MG <20 mmHg), and how these patients compare with concordant gradient moderate AS (MG >20 mmHg) in terms of patients' characteristics and the impact on long term prognosis.

Methods: Based on the echocardiographic findings at the time of diagnosis of moderate AS (valve area >1.0 and ≤1.5 cm2), they were re-classified into discordant or concordant gradients, MG <20 mmHg or >20 mmHg, respectively. The clinical endpoint was all-cause mortality.

Results: Of 522 patients with moderate AS, 95 (18.2%) had discordant gradient moderate AS (MG <20 mmHg). Patients with discordant mean gradient were older, had higher prevalence of previous myocardial infarct, larger left ventricular (LV) end-diastolic volume index, lower LV ejection fraction (EF), stroke volume index and higher LV filling pressure. Compared to patients with concordant gradients, these patients had higher mortality rates (57.9% vs 46.6%, p=0.05) and lower aortic valve replacement rates (33.7% vs 54.9%, p<0.001) during a median follow-up of 6.2 [IQR 3.2–9.0] years. The results of Cox regression analysis are shown on the table.

Conclusion: Discrepant aortic mean gradient in moderate AS is not uncommon and occurs more often in older patients, with higher LV filling pressure and lower EF and stroke volume index. The lower gradient values lead to underestimation of AS severity, and is associated with greater cardiac extra-valvular damage and higher mortality.

Cox proportional hazard analysis
All-cause mortalityUnivariate analysisMultivariate analysis
Hazard ratio (95% CI)P valueHazard ratio (95% CI)P value
Age (per 1 year increase)1.05 (1.03–1.06)<0.0011.04 (1.02–1.06)<0.001
Diabetes (yes/no)1.34 (1.03–1.74)0.0311.33 (0.97–1.82)0.072
Previous myocardial infarction (yes/no)1.73 (1.29–2.34)<0.0011.01 (0.70–1.46)0.980
eGFR <60 ml/min/1.73m2 (yes/no)2.15 (1.68–2.76)<0.0011.71 (1.25–2.33)0.001
Left ventricular hypertrophy (yes/no)1.74 (1.31–2.30)<0.0011.50 (1.07–2.09)0.018
Indexed LA volume (per 1 mL/m2 increase)1.005 (1.001–1.009)0.0081.006 (1.001–1.012)0.040
Tricuspid regurgitation >moderate (yes/no)2.02 (1.29–3.16)0.0021.36 (0.73–2.54)0.337
Discordant moderate AS (yes/no)1.81 (1.34–2.45)<0.0011.42 (1.01–2.01)0.049
AS, aortic stenosis; CI, confidence interval; eGFR, estimated glomerular filtration rate; HR, hazard ratio; LA, Left atrial.

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