Impact of Mean Transaortic Pressure Gradient on Long‐Term Outcome in Patients With Severe Aortic Stenosis and Preserved Left Ventricular Ejection Fraction

Abstract

BackgroundMean transaortic pressure gradient (MTPG) has never been validated as a predictor of mortality in patients with severe aortic stenosis. We sought to determine the value of MTPG to predict mortality in a large prospective cohort of severe aortic stenosis patients with preserved left ventricular ejection fraction and to investigate the cutoff of 60 mm Hg, proposed in American guidelines.Methods and ResultsA total of 1143 patients with severe aortic stenosis defined by aortic valve area ≤1 cm2 and MTPG ≥40 mm Hg were included. The population was divided into 3 groups according to MTPG: between 40 and 49 mm Hg, between 50 and 59 mm Hg, and ≥60 mm Hg. The end point was all‐cause mortality. MTPG was ≥60 mm Hg in 392 patients. Patients with MTPG ≥60 mm Hg had a significantly increase risk of mortality compared with patients with MTPG <60 mm Hg (hazard ratio [HR]=1.62 [1.27–2.05] P<0.001), even for the subgroup of asymptomatic or minimally symptomatic patients (HR=1.56 [1.04–2.34] P=0.032). After adjustment for established outcome predictors, patients with MTPG ≥60 mm Hg had a significantly higher risk of mortality than patients with MTPG <60 mm Hg (HR=1.71 [1.33–2.20] P<0.001), even after adjusting for surgery as a time‐dependent variable (HR=1.71 [1.43–2.11] P<0.001). Similar results were observed for the subgroup of asymptomatic or minimally symptomatic patients (HR=1.70 [1.10–2.32] P=0.018 and HR=1.68 [1.20–2.36] P=0.003, respectively).ConclusionsThis study shows the negative prognostic impact of high MTPG (≥60 mm Hg), on long‐term outcome of patients with severe aortic stenosis with preserved left ventricular ejection fraction, irrespective of symptoms.

Relationship Between the Ratio of Acceleration Time/Ejection Time and Mortality in Patients With High‐Gradient Severe Aortic Stenosis

“…More important, AT/ET provided incremental prognostic information over established predictors of outcome in SAS, thereby suggesting that in clinical daily practice, assessment of AT/ET should be systematically performed in patients with asymptomatic or minimally symptomatic SAS with preserved LVEF and taken into consideration for decision purposes (Figure 7 ). 22 , 23 , 24 , 25 , 26 , 27 …”

“… AT/ET indicates ratio of acceleration time/ejection time; AVR, aortic valve replacement; BNP, brain natriuretic peptide 22 ; echo, echocardiographic; GLS, global longitudinal strain 4 ; LAVI, left atrial volume index 26 ; LV‐SVi, left ventricular stroke volume index 5 ; LVEF, left ventricular ejection fraction 23 ; MTPG, mean transaortic pressure gradient 25 ; severe valve calcification and aortic peak jet velocity (Vmax) progression, >0.3 m/s per year 24 ; and Vmax, aortic peak jet velocity. 27 …”

Predicting outcomes in patients with aortic stenosis using machine learning: the Aortic Stenosis Risk (ASteRisk) score

“…We chose a BLR threshold of 85% (rather than 90%) to incorporate mean gradient as a feature. We did this because numerous studies have established the predictive power of mean gradient in AS23–27 and mean gradient is a central tenet of clinical AS risk assessment 3 9. We therefore believed that any model that left out mean gradient will be viewed with scepticism in the clinical community.…”

The Role of Imaging in Measuring Disease Progression and Assessing Novel Therapies in Aortic Stenosis

“…Although multiple echocardiographic parameters exist to assess disease severity, current guidelines recommend the assessment of severity and progression based on peak velocity, mean gradient, and aortic valve area (AVA) (23). Each of these central parameters have been found to predict outcome across multiple studies 24, 25, 26. Aortic peak velocity remains the first-line biomarker in the European Society of Cardiology/European Association for Cardio-Thoracic Surgery 2017 guidelines, providing powerful prognostic information and superior reproducibility than other parameters 27, 28.…”