Severe aortic stenosis patients with preserved ejection fraction according to flow and gradient classification: Prevalence and outcomes

Int J Cardiol. 2017 Dec 1:248:211-215. doi: 10.1016/j.ijcard.2017.06.064. Epub 2017 Aug 30.


Background: Clinicians often encounter patients with apparently discordant echocardiographic findings, severe aortic stenosis (SAS) defined by aortic valve area (AVA) despite a low mean gradient. A new classification according to flow state and pressure gradient has been proposed. We sought to assess the prevalence, characteristics and outcomes of patients with asymptomatic SAS with preserved left-ventricular ejection fraction (LVEF) according to flow and gradient.

Methods and results: In total 442 patients with SAS (AVAi<0.6 cm2/m2) and LVEF ≥50% (mean age 80+11years, 54,5% female) were included. Patients were classified according to flow state (≥ or <35ml/m2) and mean pressure gradient (≥ or <40mmHg): Low Flow/Low Gradient (LF/LG): 21.3%(n=94); Normal Flow/Low Gradient (NF/LG): 32.1%(n=142); Low Flow/High Gradient (LF/HG): 6.8%(n=30); Normal Flow/High Gradient (NF/HG): 39,8%(n=176). Mean follow-up time was 20.5months (SD=10.3). Primary combined endpoint was cardiovascular mortality and hospital admission for SAS related symptom, secondary endpoint was aortic valve replacement (AVR), comparing HG group to LF/LG group. During follow-up 17 (18%) of LF/LG patients and 21 (10.2%) of HG patients met the primary endpoint. A lower free of event survival (cardiovascular mortality and hospital admission) was observed in patients with LF/LG AS (Breslow, p=0.002). Significant differences were noted between groups with a lower AVR free survival in the LF/LG group compared to HG groups (Breslow, p=0.002).

Conclusions: Our study confirms the high prevalence and worse prognosis of LF/LG SAS. Clinicians must be aware of this entity to ensure appropriate patient management.

Keywords: Echocardiography; Low flow/low gradient; Preserved left ventricular ejection fraction; Severe aortic stenosis.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Aortic Valve Stenosis / diagnostic imaging*
  • Aortic Valve Stenosis / mortality
  • Aortic Valve Stenosis / physiopathology*
  • Echocardiography, Doppler / trends
  • Female
  • Follow-Up Studies
  • Fractional Flow Reserve, Myocardial / physiology*
  • Humans
  • Male
  • Prevalence
  • Retrospective Studies
  • Severity of Illness Index*
  • Stroke Volume / physiology*
  • Treatment Outcome