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Paradoxical low-flow/low-gradient severe aortic stenosis: prevalence and distinctive characteristics in comparison to high-gradient aortic stenosis
Background: Paradoxical low-flow/ low-gradient aortic stenosis (PAS) has been described in up to 30% of patients with AS and preserved left ventricular ejection fraction (LVEF), and characterized by a higher prevalence of female sex, small body surface area, older age and systemic hypertension. Moreover, some reports showed this subtype of AS to have an increased risk of mortality compared with other subtypes of AS with preserved LVEF (normal-flow/ low-gradient and high-gradient).
Purpose: To evaluate the prevalence of PAS and to compare clinical and echocardiographic characteristics, differences in therapeutic management and overall survival between patients with this entity and those with classical high-gradient (HG) AS.
Methods: Single center, retrospective study of patients with severe AS evaluated by transthoracic echocardiography between January 2012 and May 2017. All patients with severe PAS (AVA 1 cm2, MG<40 mmHg and SVi<35 ml/m2) were selected. For the control group, the first patient with classical HG AS of each month throughout this 5-year period was selected. Clinical, echocardiographic, types of treatment and outcome data were assessed and compared between groups.
Results: Out of 1250 patients with AS evaluated over this period, only 34 (2,7%) fulfilled the criteria for paradoxical severe AS, with a mean age of 78±6 years and 56% of female patients. The control group included 65 patients with severe classical HG AS, with a mean age of 77±9 years, 51% females. Using a binary logistic regression, the variables that correlated significantly with paradoxical AS were: atrial fibrillation (AF) rhythm (OR 30 with 95% C.I. [6, 161], p<0.01), at least moderate mitral regurgitation (MR) (OR 6 with 95% C.I. 1, 29], p 0.02), and right ventricular (RV) dysfunction (OR 35 with a 95% C.I. [2, 533], p 0.01). No differences were observed between the 2 groups regarding gender, age, hypertension, body surface area, chosen management strategy (medical therapy vs valvular replacement), type of treatment used (TAVI vs conventional surgery) or outcome.
Conclusion: In our population, paradoxical low-flow/low-gradient AS is a rare subtype of AS. In comparison with patients with classical HG AS, patients with PAS are characterized by a higher prevalence of AF, moderate or severe mitral regurgitation and RV dysfunction. We did not find differences regarding the chosen therapeutical management or outcome.
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