Besir Besir, Lomaia Tamari, Ramu Shivabalan Kathavarayan, Rajendran Judah, Reed Grant W, Puri Rishi, Harb Serge C, Popovic Zoran, Krishnaswamy Amar, Kapadia Samir R
Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.
Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.
Prog Cardiovasc Dis. 2025 Sep 8. doi: 10.1016/j.pcad.2025.09.005.
This study explores the impact of lower baseline aortic valve (AV) mean gradients on the clinical outcomes of patients with low-gradient aortic stenosis (LG AS) post-transcatheter aortic valve replacement (TAVR). Additionally, the study aims to understand the predictors of a lower baseline AV mean gradient (MG).
Reduced left ventricular ejection fraction (LVEF) and low-flow states are known to correlate with worse clinical outcomes. Lower mean gradients are also known to correlate with poorer outcomes, but the outcomes of patients with very low-gradient AS compared to low-gradient AS are not well understood.
This is a retrospective cohort of patients >18 years who underwent TAVR at Cleveland Clinic between 2016 and 2020. Only patients with AV area < 1 cm, and AV MG <40 mmHg were included. Patients who underwent valve-in-valve TAVR were excluded. Patients were classified into 3 tertiles according to their baseline AV MG. Clinical outcomes included mortality and heart failure hospitalization. Survival analysis was used to assess the clinical outcomes between the tertiles.
Around 60 % of the patients in this study were males, with a mean age of 80 years. The mean AV MG was 21.8 ± 4.0 mmHg for the first tertile, 30.9 ± 1.9 mmHg for the second tertile, and 37.1 ± 1.6 mmHg for the third tertile. The present study shows that patients with very low-gradient AS (first tertile) have higher mortality rates compared to those with low-gradient AS (third tertile) (hazard ratio: 2.07, 95 % confidence interval (1.2-3.6)), even after stratifying by flow and by LVEF. Lower stroke volume index (SVI), lower LVEF, atrial fibrillation, and moderate to severe TR were associated with lower mean gradients.
Patients with very low-gradient AS have worse outcomes than those with low-gradient AS. Multiple clinical characteristics, including a lower SVI, lower LVEF, and atrial fibrillation, correlate with having very low-gradient AS. Therefore patients with low-gradient AS should undergo earlier intervention to improve their clinical outcomes.
本研究探讨较低的基线主动脉瓣（AV）平均压差对经导管主动脉瓣置换术（TAVR）后低压差主动脉瓣狭窄（LG AS）患者临床结局的影响。此外，该研究旨在了解较低基线AV平均压差（MG）的预测因素。
已知左心室射血分数（LVEF）降低和低流量状态与更差的临床结局相关。较低的平均压差也与较差的结局相关，但极低压差AS患者与低压差AS患者的结局尚未得到充分了解。
这是一项对2016年至2020年间在克利夫兰诊所接受TAVR的18岁以上患者的回顾性队列研究。仅纳入AV面积<1 cm且AV MG<40 mmHg的患者。接受瓣中瓣TAVR的患者被排除。根据患者的基线AV MG将其分为三个三分位数。临床结局包括死亡率和心力衰竭住院率。采用生存分析评估三分位数之间的临床结局。
本研究中约60%的患者为男性，平均年龄为80岁。第一个三分位数的平均AV MG为21.8±4.0 mmHg，第二个三分位数为30.9±1.9 mmHg，第三个三分位数为37.1±1.6 mmHg。本研究表明，即使在按流量和LVEF分层后，极低压差AS患者（第一个三分位数）的死亡率仍高于低压差AS患者（第三个三分位数）（风险比：2.07，95%置信区间[1.2 - 3.6]）。较低的每搏输出量指数（SVI）、较低的LVEF、心房颤动以及中度至重度三尖瓣反流（TR）与较低的平均压差相关。
极低压差AS患者的结局比低压差AS患者更差。包括较低的SVI、较低的LVEF和心房颤动在内的多种临床特征与极低压差AS相关。因此，低压差AS患者应尽早接受干预以改善其临床结局。
