True-severe Stenosis 1 in Paradoxical Low-flow Low-gradient Aortic Stenosis: Outcomes after Transcatheter Aortic Valve Replacement.

Abstract

AIMS\nThe ESC/EACTS guidelines propose criteria that determine the likelihood of true-severe aortic stenosis (AS). We aimed to investigate the impact of the guideline-based criteria of the likelihood of true-severe AS in patients with low-flow low-gradient (LFLG) AS with preserved ejection fraction (pEF) on outcomes following transcatheter aortic valve replacement (TAVR).\n\n\nMETHODS AND RESULTS\nIn a prospective TAVR registry, LFLG-AS patients with pEF were retrospectively categorized into high (criteria ≥6) and intermediate (criteria <6) likelihood of true-severe AS. Hemodynamic, functional and clinical outcomes were compared with high-gradient AS patients with pEF. Among 632 eligible patients, 202 fulfilled diagnostic criteria for LFLG-AS. Significant hemodynamic improvement after TAVR was observed in LFLG-AS patients, irrespective of the likelihood. Although >70% of LFLG-AS patients had functional improvement, impaired functional status (NYHA III/IV) persisted more frequently at 1 year in LFLG-AS than in high-gradient AS patients (7.8%), irrespective of the likelihood (high: 17.4%, p\u2009=\u20090.006; intermediate: 21.1%, p\u2009<\u20090.001). All-cause death at 1 year occurred in 6.6% of high-gradient AS patients, 10.9% of LFLG-AS patients with high likelihood (HRadj 1.43, 95%CI 0.68-3.02), and in 7.2% of those with intermediate likelihood (HRadj 0.92, 95%CI 0.39-2.18). Among the criteria, only the absence of AVA ≤0.8\u2009cm2 emerged as an independent predictor of treatment futility, a combined endpoint of all-cause death or NYHA III/IV at 1 year (OR 2.70, 95%CI 1.14-6.25).\n\n\nCONCLUSION\nPatients with LFLG-AS with pEF had comparable survival but worse functional status at 1 year than high-gradient AS with pEF, irrespective of the likelihood of true-severe AS.\n\n\nCLINICAL TRIAL REGISTRATION\nhttps://www.clinicaltrials.gov. NCT01368250.