Objectives: This study was designed to assess which hemodynamic index best accounts for clinical severity of aortic stenosis (AS) and to analyze the value of low-dose dobutamine testing.
Background: Pressure gradient and valve area are suboptimal because they depend on flow rate, correlate poorly with symptoms, and provide limited prognostic information. Recently, new indices and low-dose inotropic stimulation have been introduced, but their clinical value remains uncertain.
Methods: A total of 307 consecutive patients with AS were included in an ambispective study design (71 +/- 12 years old; peak jet velocity: 3.7 +/- 1.1 m/s). Clinical and Doppler-echocardiographic data were obtained, as well as results of low-dose dobutamine infusion (47 patients). Using receiver-operator-characteristic curve analysis, we evaluated jet velocity, pressure gradient, valve area, resistance, stroke-work loss (SWL), and dobutamine-induced increase in area for predicting 1) symptomatic status at entry, 2) early (</=3 months) cardiovascular death or aortic valve replacement, and 3) long-term outcome. Logistic regression and Cox models were designed multivariate and adjusted by bootstrapping.
Results: Only 28% of patients were alive without valve replacement at the end of the follow-up period (22 +/- 4 months). The decision for valve replacement was made by the referring physician, blinded to the SWL, valve resistance, and dobutamine results. Non-flow-corrected indices performed better than valve area and valve resistance. Among them, SWL best predicted the defined end points. Odds/hazard ratios associated with a SWL Delta = 17% were 5.14 for presenting AS symptoms, 4.68 for early events, and 2.31 for late outcome. A cutoff value of SWL >25% best discriminated clinical end points. Other independent predictors of prognosis were symptomatic status and left ventricular ejection fraction. Dobutamine testing added no value to baseline models.
Conclusions: Non-flow-corrected indices show the highest clinical efficacy in aortic stenosis. Among these, SWL best predicts symptomatic status and outcome and therefore should be incorporated to aid patient management in unclear situations.