Courtesy of Dr. Carlos Fava.

It is known that patients with low gradient aortic stenosis show poor evolution with medical treatment and, in addition, present high mortality rate with surgery. As regards TAVR, a far simpler procedure compared to surgery, there is contradicting evidence; while some studies claim it holds comparable risks, others have found benefits.

This study analyzed 8 studies including a total of 12,589 patients. Low gradient aortic stenosis was defined as aortic valve area (AVA) <1 cm2 with a mean gradient lower than 40 mmHg, except for Malkin, who defined it as AVA <1.

Primary end point was all cause mortality at 12 months, while the secondary was all cause mortality at 30 days.

All patients presented severe symptomatic aortic stenosis. 3,437 (27.3%) of them presented low gradient aortic stenosis.

Mean age was 81. Ejection fraction was lower in those presenting low gradient aortic stenosis (48% vs. 54%), higher presence of diabetes, coronary artery disease and EuroSCORE log.

Primary end point was higher in the low gradient AS group (OR; 1.48; 95% CI; 1.3-1.7; p<0.00001), as well as the secondary end point (OR, 1.35; 95% CI, 1.11-1.66; p=0.002). As regards age, ejection fraction, a history of heart disease and type of implanted valve, these factors did not impact mortality in the low gradient group.

Conclusion

In a population of patients undergoing TAVR, the presence of low gradient aortic stenosis seems to be associated to a dismal prognosis.

Comment

The presence of low flow and low gradient is a challenge in this disease, since it is associated with higher early mortality after surgery, and this analyzis shows the same.

We should learn to be wary not only of AS diagnosis (acknowledging symptoms, assessing ventricular function and ejection fraction), but also of systolic volume index, associated to early ventricular function deterioration.

Courtesy of Dr. Carlos Fava.

Original Title: Outcomes of Patients with Low-Pressure Aortic Gradient Undergoing Transcatheter Aortic Valve Implantation: a Meta-analysis.

Reference: Federico Carnotto, et al. Catheterization and Cardiovascular Intervention 2017;89:1100-1106.

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