Abstract 15714: Aortic Stenosis Severity Grading: Resolving the Conundrum of Discordant Grading in a Very Large Cohort
Introduction: Aortic stenosis (AS) with discordant severity grading (low mean gradient [MG], tight indexed aortic valve area [AVAi] despite normal ejection fraction [EF]) is frequent and alternatively reported as moderate (benign outcome) or severe (poor survival). Clinical management of these patients remains uncertain and aortic valve replacement (AVR) is rarely offered.
Aim: To gather a very large AS cohort and assess survival under medical management in all AS grading categories.
Methods: We enrolled all consecutive patients diagnosed with isolated (no other valve disease or surgery) AS (MG ≥ 10 mmHg and AVA ≤ 1.5 cm2 and/or Vpeak ≥ 2 m/s) 2001-13. Patients with major comorbidity and EF<50% were excluded. Then patients classified according to MG< or ≥ 40 mmHg and AVAi ≤ or > 0.6 cm2/m2.
Results: Among our 6,279 patients, 2,168 were classified as severe AS (SAS: MG ≥ 40 mmHg and AVAi ≤ 0.6 cm2/m2); 2,683 as moderate AS (MAS: MG <40 mmHg and AVAi > 0.6 cm2/m2); 130 as Discordant with high MG (DHG: MG ≥ 40 mmHg and AVAi > 0.6 cm2/m2) and 1,298 as Discordant with Low MG (DLG: MG <40 mmHg and AVAi ≤ 0.6 cm2/m2). During a mean follow-up of 3.6±3.7 years under medical management, there were 2,269 deaths. Survival at 8 years was 37% in SAS vs. 46% in MAS and patients with DHG had a better survival (54% p=0.07) than MAS and those with DLG had survival worse than MAS (40%, p=0.05). In multivariate analysis adjusted for sex, age, body mass index, EF, symptoms, comorbidity score, and mitral regurgitation, groups independently predicted mortality with excess mortality (1.19[1.07-1.32]) in DLG vs. MAS and (1.44 [1.28-1.61]) in SAS vs. MAS. Conversely, excess mortality was noted among patients in SAS vs. DHG (1.41 [1.00-2.09]) and in SAS vs. DLG (1.21[1.06-1.38]). In multivariate analysis, AVAi (1.05 [1.02-1.08] per 0.1cm2 decrease; p=0.0007) and MG (1.02 [1.00-1.05] per 5 mmHg increase; p=0.04) independently predicted mortality.
Conclusion: The present very large and consecutive study shows that both AVAi and MG are independent determinants of survival after AS diagnosis and should be considered in evaluating AS severity. Patients with discordant tight AVA and low MG are at high risk, intermediate between SAS and MAS and should be carefully evaluated for aortic valve replacement.
Author Disclosures: M. Clavel: None. J. Malouf: None. H.I. Michelena: None. M. Enriquez-Sarano: None.
- © 2016 by American Heart Association, Inc.