Impact of Mean Transaortic Pressure Gradient on Long-Term Outcome in Patients with Severe Aortic Stenosis and Preserved Left Ventricular Ejection Fraction

Abstract

Background--Mean transaortic pressure gradient (MTPG) has never been validated as a predictor of mortality in patients with severe aortic stenosis. We sought to determine the value of MTPG to predict mortality in a large prospective cohort of severe aortic stenosis patients with preserved left ventricular ejection fraction and to investigate the cutoff of 60 mm Hg, proposed in American guidelines.Methods and Results--A total of 1143 patients with severe aortic stenosis defined by aortic valve area ≤1 cm 2 and MTPG ≥40 mm Hg were included. The population was divided into 3 groups according to MTPG: between 40 and 49 mm Hg, between 50 and 59 mm Hg, and ≥60 mm Hg. The end point was all-cause mortality. MTPG was ≥60 mm Hg in 392 patients. Patients with MTPG ≥60 mm Hg had a significantly increase risk of mortality compared with patients with MTPG <60 mm Hg (hazard ratio [HR] =1.62 [1.27-2.05] P<0.001), even for the subgroup of asymptomatic or minimally symptomatic patients (HR=1.56 [1.04-2.34] P=0.032). After adjustment for established outcome predictors, patients with MTPG ≥60 mm Hg had a significantly higher risk of mortality than patients with MTPG <60 mm Hg (HR=1.71 [1.33-2.20] P<0.001), even after adjusting for surgery as a timedependent variable (HR=1.71 [1.43-2.11] P<0.001). Similar results were observed for the subgroup of asymptomatic or minimally symptomatic patients (HR=1.70 [1.10-2.32] P=0.018 and HR=1.68 [1.20-2.36] P=0.003, respectively).Conclusions--This study shows the negative prognostic impact of high MTPG (≥60 mm Hg), on long-term outcome of patients with severe aortic stenosis with preserved left ventricular ejection fraction, irrespective of symptoms. ( J Am Heart Assoc. 2017;6: e005850.AS indicates aortic stenosis; MTPG, mean transaortic pressure gradient. *P for global comparison. † Model 1: adjustment for age, sex, body surface area, hypertension, coronary artery disease, history of atrial fibrillation, comorbidity index, and ejection fraction. ‡ Model 2: adjustment for age, sex, body surface area, hypertension, coronary artery disease, history of atrial fibrillation, comorbidity index, ejection fraction, and aortic valve surgery as a time-dependent covariate.

Balloon Aortic Valvuloplasty in Patients Admitted for Cardiogenic Shock with Severe Aortic Stenosis: A Retrospective Analysis of 14 Cases

“…Our emergent patients' mean aortic gradient before the procedure was similar to Cribier’s patients [7] and higher than Debry’s [22]. More than half of emergent patients had values higher than 60 mmHg, a cut-off value proven to be associated with even greater mortality [24].…”

Hemodynamic Classifications of Aortic Stenosis and Relevance to Prognosis

“…They found that MG > 60 mmHg at baseline was associated with greater risk of all-cause mortality than lower values, thereby justifying a separate hemodynamic classification. The higher MG also reflected the chronicity of the disease process [28] (see Figure 5).…”

Echocardiographic assessment of aortic stenosis: a practical guideline from the British Society of Echocardiography

“…Once the AV Vmax is ≥5 m/s, survival is reduced even in the absence of symptoms ( 40 , 43 , 44 ). Similarly, a mean gradient ≥60 mmHg and an AVA ≤0.6 cm 2 are associated with extremely high event rates and largely correspond with an AV Vmax of 5 m/s ( 45 , 46 , 47 ). American guidelines advocate surgery in such patients even in the absence of symptoms (Class IIa indication) ( 6 ).…”