Prognosis of paradoxical low-flow low-gradient aortic stenosis after transcatheter aortic valve replacement

Abstract

Aims In paradoxical low-flow low-gradient severe aortic stenosis (PLFLG AS) patients, stroke volume index (SVI) is reduced despite preserved left ventricular ejection fraction (LVEF). Although reduced SVI is already known as a poor prognostic predictor, the outcomes of PLFLG AS patients after transcatheter aortic valve replacement (TAVR) have not been clearly defined. We retrospectively investigated the post-TAVR outcomes of PLFLG AS patients in comparison with normal-flow high-gradient aortic stenosis (NFHG AS) patients. Methods The current observational study included 245 patients with NFHG AS (mean transaortic pressure gradient ≥40 mmHg and LVEF ≥ 50%) and 48 patients with PLFLG AS (mean transaortic pressure gradient <40 mmHg, LVEF ≥ 50% and SVI < 35 ml/m2). The endpoints were all-cause mortality, hospitalization for valve-related symptoms or worsening congestive heart failure and New York Heart Association functional class III or IV. Results PLFLG AS patients had a significantly higher proportion with a history of atrial fibrillation/flutter as compared with NFHG AS patients. All-cause mortality of PLFLG AS patients was worse than that of NFHG AS patients (P = 0.047). Hospitalization for valve-related symptoms or worsening congestive heart failure was more frequent in PLFLG AS patients than in NFHG AS patients (P = 0.041). New York Heart Association functional class III–IV after TAVR was more frequently observed in PLFLG AS patients (P = 0.019). Conclusion The outcomes of PLFLG AS patients were worse than those of NFHG AS patients in this study. Preexisting atrial fibrillation/flutter was frequent in PLFLG AS patients, and may affect their post-TAVR outcomes. Therefore, closer post-TAVR follow-up should be considered for these patients.

Diastolic dysfunction and clinical outcomes after transcatheter or surgical aortic valve replacement in patients with atypical aortic valve stenosis

“…Several studies have suggested that patients with atypical aortic stenosis are a higher-risk cohort of patients hampered by an increased risk of adverse cardiovascular events. 24,25 Indeed, Saito et al 25 illustrated that diastolic dysfunction was highly prevalent in patients with severe aortic stenosis undergoing TAVR. They found that patients with increasing grades of diastolic dysfunction had higher rates of all-cause mortality at 1 year, mainly because of higher rates of cardiovascular death.…”

What we have learnt in valvular heart disease from our journal

“…The indication to treat paradoxical low-flow low-gradient AS is weaker than that to high gradient AS. Indeed, patients with paradoxical low-flow low-gradient AS undergoing TAVI seem to have a worse early and mid-term prognosis as compared with those with normal-flow high-gradient AS 23 …”

“…Indeed, patients with paradoxical low-flow low-gradient AS undergoing TAVI seem to have a worse early and midterm prognosis as compared with those with normal-flow high-gradient AS. 23 The role of TAVI in the emergent setting is also debated. However, a recent single-center study reported a higher survival rate in patients with decompensated AS undergoing urgent or emergent TAVI compared with those receiving urgent or emergent balloon valvuloplasty.…”

Prognostic value of coronary microvascular dysfunction in patients with aortic stenosis and nonobstructed coronary arteries

“…Aortic valve stenosis is a common valvular disease that manifests clinically as dyspnoea, angina, and syncope, and its prevalence increases with age, affecting 3% of persons more than 65 years old. [1][2][3] Severe aortic valve stenosis and the development of left ventricular hypertrophy (LVH) are associated with significant changes in microvascular haemodynamics. [4][5][6] Patients with aortic valve stenosis have been shown to have coronary microvascular dysfunction (CMD) reflected by reduced coronary flow reserve (CFR) and a high index of microvascular resistance (IMR) despite nonobstructive coronary stenosis, 4,[6][7][8][9] which limits coronary blood flow while increasing oxygen demand, causing myocardial ischaemia.…”

“…Aortic valve stenosis is a common valvular disease that manifests clinically as dyspnoea, angina, and syncope, and its prevalence increases with age, affecting 3% of persons more than 65 years old 1–3 . Severe aortic valve stenosis and the development of left ventricular hypertrophy (LVH) are associated with significant changes in microvascular haemodynamics 4–6 .…”