Aortic Stenosis with Normal Flow Low Gradient: Should We Intervene or Wait?

Symptomatic patients with <1 cm² aortic valve area will benefit from an intervention regardless parameters such as flow and gradient, even if these are normal (or at least not severe).

A valve replacement will be indicated without question (either surgical or percutaneous) in patients with >40 mHg mean gradient or low gradient justified by low flow. Much has been said and written about these cases and much will still be written. However, little has been published about patients with normal flow and low gradient.

Should we trust aortic valve area blindly when indicating an intervention such as a valve replacement?

Read also: Ten Commandments of the European Hypertension Guidelines: Several “Sins Allowed” Compared with American Guidelines.

Many specialists might question the severity of stenosis in these patients, especially when symptoms can be explained by other causes such as pulmonary or coronary causes.

This study included symptomatic patients with ≤ 1 cm² valve area, <40 mmHg mean gradient and > 35 ml/m² stroke volume index.

During the study period,1358 patients were assessed, and 303 (34%) met inclusion criteria.

Read also: TAVR Post-dilation Is Safe.

After a mean follow up of nearly 2 years, 60 patients (20%) died, with a global rate of 28%, 10% and 12% in the conservative treatment branch, TAVR and surgery respectively (p<0.001).

After adjusting for multiple variables, TAVR was associated with survival improvement vs. the conservative treatment (HR: 0.49; CI 95%:0.26 to 0.93; p=0.03), with no significant differences between surgery and TAVR. What made the difference was the intervention, regardless the type.

Conclusion

Symptomatic patients with <1 cm² valve area will benefit from intervention in terms of survival regardless low gradient and normal flow. The type of intervention had no impact on outcomes.

Original title: Intervention Versus Observation in Symptomatic Patients with Normal Flow-Low Gradient Severe Aortic Stenosis.

Reference: Oren Zusman et al. J Am Coll Cardiol Img 2018. Article in press.

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