Is the Acceleration Time/Ejection Time Ratio Superior to the Mean Gradient in Predicting Clinical Outcomes After TAVR?

Courtesy of Dr. Juan Manuel Pérez.

Traditionally, the mean gradient (MG) has been used to assess post-TAVR outcomes. However, this parameter may be influenced by cardiac output and pressure recovery, limiting its prognostic value. In this context, the acceleration time-to-ejection time ratio (AT/ET) has emerged as an alternative index. The aim of this study was to compare the predictive value of AT/ET versus MG for clinical outcomes after TAVR.

This retrospective, single high-volume center study included 1,900 patients who underwent TAVR between 2016 and 2020. Patients were stratified according to AT/ET ≥0.35 (n=256; 13.5%) or <0.35 (n=1,644; 86.5%), measured within 3 months post-implant. A value ≥0.35 reflects increased resistance to transvalvular flow, while a value <0.35 indicates a more favorable flow gradient. 

The mean age was 78 years, with male predominance. No significant differences were observed in comorbidities, NYHA class III/IV, or STS risk scores between groups. In the AT/ET ≥0.35 group, ejection fraction was lower (52.3% vs. 57.8%; p<0.001) and blood pressure was lower (125 ± 21 vs. 134 ± 21 mmHg; p<0.001). Regarding valve type, 23.2% of patients with higher AT/ET received self-expanding valves, compared with 12.7% who received balloon-expandable valves (p=0.001).

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The primary endpoint was hospitalization for heart failure (HFH) at 1 year; the secondary endpoint was all-cause mortality. At 1 year, the AT/ET ≥0.35 group had a higher rate of HFH (12.8% vs. 5.2%; HR 2.25, CI 95%: 1.43–3.53; p<0.001). This difference was observed both in self-expanding valves (HR 6.79; CI 95%: 1.66–27.66; p=0.007) and balloon-expandable valves (HR 1.9; CI 95%: 1.15–3.12; p=0.01). No differences in mortality were found (8.5% vs. 7.2%; HR 1.20; CI 95%: 0.70–2.05; p=0.50). In contrast, a mean gradient ≥20 mmHg was not significantly associated with HFH or mortality (p=0.46 and p=0.76, respectively).

Conclusión

In conclusion, this is the largest study to demonstrate that an AT/ET ratio ≥0.35 after TAVR predicts a higher risk of HFH at 1 year, regardless of valve type, while MG showed no prognostic value. These findings suggest that AT/ET may represent a more reliable marker of prosthetic valve function and clinical outcomes post-TAVR.

Original Title: Acceleration Time/Ejection Time Ratio Compared to Mean Gradient as a Predictor of Clinical Outcomes Post-TAVR.

Reference: Tamari Lomaia et al. JACC: Cardiovascular Interventions, Volumen 18, 2270–2279, 2025.