Outcome of Flow-Gradient Patterns of Aortic Stenosis After Aortic Valve Replacement: An Analysis of the PARTNER 2 Trial and Registry.

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Citation: Circulation: Cardiovascular Interventions. 13(7):e008792, 2020 Jul.PMID: 32674676Institution: MedStar Heart & Vascular InstituteForm of publication: Journal ArticleMedline article type(s): Journal ArticleSubject headings: IN PROCESS -- NOT YET INDEXEDYear: 2020ISSN:
  • 1941-7640
Name of journal: Circulation. Cardiovascular interventionsAbstract: BACKGROUND: Although aortic valve replacement is associated with a major benefit in high-gradient (HG) severe aortic stenosis (AS), the results in low-gradient (LG, mean gradient <40 mm Hg) AS are conflicting. LG severe AS may be subdivided in classical low-flow (left ventricular ejection fraction <50%) and LG (CLF-LG); paradoxical low-flow (left ventricular ejection fraction >=50% but stroke volume index <35 mL/m2) and LG; and normal-flow (left ventricular ejection fraction >=50% and stroke volume index >=35 mL/m2) and LG. The primary objective is to determine in the PARTNER 2 trial (The Placement of Aortic Transcatheter Valves) and registry the outcomes after aortic valve replacement of the 4 flow-gradient groups.CONCLUSIONS: The LG AS pattern was highly prevalent (36.5%) in the PARTNER 2 trial and registry. CLF-LG was the most common pattern of LG AS and was associated with higher rates of death, rehospitalization, or stroke at 2 years compared with the HG group. Clinical outcomes were as good in the LG AS groups with preserved left ventricular ejection fraction compared with the HG group.METHODS: A total of 3511 patients from the PARTNER 2 Cohort A randomized trial (n=1910) and SAPIEN 3 registry (n=1601) were included. The flow-gradient pattern was determined at baseline transthoracic echocardiography and classified as follows: (1) HG; (2) CLF-LG; (3) paradoxical low-flow-LG; and (4) normal-flow-LG. The primary end point for this analysis was the composite of (1) death; (2) rehospitalization for heart failure symptoms and valve prosthesis complication; or (3) stroke.RESULTS: The distribution was HG, 2229 patients (63.5%); CLF-LG, 689 patients (19.6%); paradoxical low-flow-LG, 247 patients (7.0%); and normal-flow-LG, 346 patients (9.9%). The 2-year rate of primary end point was higher in CLF-LG (38.8%) versus HG: 31.8% (P=0.002) and normal-flow-LG: 32.1% (P=0.05) but was not statistically different from paradoxical low-flow-LG: 33.6% (P=0.18). There was no significant difference in the 2-year rates of clinical events between transcatheter aortic valve replacement versus surgical aortic valve replacement in the whole cohort and within each flow-gradient group.All authors: Alu MC, Annabi MS, Asch FM, Beaudoin J, Bernier M, Blanke P, Clavel MA, Dahou A, Douglas PS, Gertz ZM, Hahn RT, Herrmann HC, Jaber WA, Leipsic J, Leon MB, Lindman BR, Makkar R, Miller DC, Ong G, Pibarot P, Ridard C, Rodes-Cabau J, Rodriguez L, Salaun E, Thourani VH, Toubal O, Webb JG, Weissman NJ, Zhang YFiscal year: FY2021Digital Object Identifier: Date added to catalog: 2020-09-02
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Journal Article MedStar Authors Catalog Article 32674676 Available 32674676

BACKGROUND: Although aortic valve replacement is associated with a major benefit in high-gradient (HG) severe aortic stenosis (AS), the results in low-gradient (LG, mean gradient <40 mm Hg) AS are conflicting. LG severe AS may be subdivided in classical low-flow (left ventricular ejection fraction <50%) and LG (CLF-LG); paradoxical low-flow (left ventricular ejection fraction >=50% but stroke volume index <35 mL/m2) and LG; and normal-flow (left ventricular ejection fraction >=50% and stroke volume index >=35 mL/m2) and LG. The primary objective is to determine in the PARTNER 2 trial (The Placement of Aortic Transcatheter Valves) and registry the outcomes after aortic valve replacement of the 4 flow-gradient groups.

CONCLUSIONS: The LG AS pattern was highly prevalent (36.5%) in the PARTNER 2 trial and registry. CLF-LG was the most common pattern of LG AS and was associated with higher rates of death, rehospitalization, or stroke at 2 years compared with the HG group. Clinical outcomes were as good in the LG AS groups with preserved left ventricular ejection fraction compared with the HG group.

METHODS: A total of 3511 patients from the PARTNER 2 Cohort A randomized trial (n=1910) and SAPIEN 3 registry (n=1601) were included. The flow-gradient pattern was determined at baseline transthoracic echocardiography and classified as follows: (1) HG; (2) CLF-LG; (3) paradoxical low-flow-LG; and (4) normal-flow-LG. The primary end point for this analysis was the composite of (1) death; (2) rehospitalization for heart failure symptoms and valve prosthesis complication; or (3) stroke.

RESULTS: The distribution was HG, 2229 patients (63.5%); CLF-LG, 689 patients (19.6%); paradoxical low-flow-LG, 247 patients (7.0%); and normal-flow-LG, 346 patients (9.9%). The 2-year rate of primary end point was higher in CLF-LG (38.8%) versus HG: 31.8% (P=0.002) and normal-flow-LG: 32.1% (P=0.05) but was not statistically different from paradoxical low-flow-LG: 33.6% (P=0.18). There was no significant difference in the 2-year rates of clinical events between transcatheter aortic valve replacement versus surgical aortic valve replacement in the whole cohort and within each flow-gradient group.

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