Prediction of symptom development and aortic valve replacement in patients with low-gradient severe aortic stenosis

Abstract Aims Current evidence on the prognostic value of exercise stress echocardiography (ESE) in asymptomatic patients with low-gradient severe aortic stenosis (AS) is limited. Therefore, this study aimed to elucidate its prognostic implications for patients with low-gradient severe AS and determine the added value of ESE in risk stratification for this population. Methods and results This retrospective observational study included 122 consecutive asymptomatic patients with either moderate mean pressure gradient (MPG) 40 mmHg and aortic valve area (AVA) 1.0–1.5 cm2 or low-gradient severe (MPG 40 mmHg and AVA 1.0 cm2) AS and preserved left ventricular ejection fraction (≥50%) who underwent ESE. All patients were followed up for AS-related events. Of 143 patients, 21 who met any exclusion criteria, including early interventions, were excluded, and 122 conservatively managed patients 76.5 (71.0–80.3) years; 48.3% male were included in this study. During a median follow-up period of 989 (578–1571) days, 64 patients experienced AS-related events. Patients with low-gradient severe AS had significantly lower event-free survival rates than those with moderate AS (log-rank test, P 0.001). Multivariable Cox regression analysis showed that the mitral E/e′ ratio during exercise was independently associated with AS-related events (hazard ratio = 1.075, P 0.001) in patients with low-gradient severe AS. Conclusion This study suggests that asymptomatic patients with low-gradient severe AS have worse prognoses than those with moderate AS. Additionally, the mitral E/e′ ratio during exercise is a useful parameter for risk stratification in patients with low-gradient severe AS.