May 1, 2026

Transvalvular Flow, Sex, and Survival After Valve Replacement Surgery in Patients With Severe Aortic Stenosis

Structured PICO

Does a pre-operative paradoxical low flow/high gradient (LF/HG) pattern increase mortality in patients with severe aortic stenosis and preserved LVEF undergoing surgical AVR?

Population

1,490 patients (544 women [37%]) with severe aortic stenosis and preserved left ventricular ejection fraction who underwent surgical aortic valve replacement (AVR).

Intervention

Pre-operative paradoxical low flow/high gradient (LF/HG) echocardiographic pattern

Comparator

Normal flow/high gradient (NF/HG), normal flow/low gradient (NF/LG), and low flow/low gradient (LF/LG) patterns

Outcome

Mortality after AVRhard clinical

Paradoxical low flow with high gradient is associated with higher mortality following surgical aortic valve replacement in patients with severe aortic stenosis and preserved LVEF, suggesting it is a marker of advanced disease severity.

Abstract

BACKGROUND: The respective impacts of transvalvular flow, gradient, sex, and their interactions on mortality in patients with severe aortic stenosis undergoing surgical aortic valve replacement (AVR) are unknown. OBJECTIVES: This study sought to compare the impact of pre-operative flow-gradient patterns on mortality after AVR and to examine whether there are sex differences. METHODS: This study analyzed clinical, echocardiographic, and outcome data prospectively collected in 1,490 patients (544 women 37%), with severe aortic stenosis and preserved left ventricular ejection fraction who underwent AVR. RESULTS: In this cohort, 601 patients (40%) had normal flow (NF) with high gradient (HG), 405 (27%) NF with low gradient (LG), 246 (17%) paradoxical low flow (LF)/HG, and 238 (16%) LF/LG. During a median follow-up of 2.42 years (interquartile range: 1.04 to 4.29 years), 167 patients died. Patients with LF/HG exhibited the highest mortality after AVR (hazard ratio HR: 2.01; 95% confidence interval CI: 1.33 to 3.03; p < 0.01), which remained significant after multivariate adjustment (HR: 1.96; 95% CI: 1.29 to 2.98; p < 0.01). Both LF/LG and NF/LG patients had comparable outcome to NF/HG (p ≥ 0.47). Optimal thresholds of stroke volume index were obtained for men (40 ml/m CONCLUSIONS: Paradoxical LF/HG was associated with higher mortality following AVR, suggesting that a reduced flow is a marker of disease severity even in patients with HG aortic stenosis. Early surgical AVR (i.e., before gradient attains 40 mm Hg) might be preferable in these patients. Furthermore, the use of sex-specific thresholds (<40 ml/m

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Cite This Study

Guzzetti et al. (Wed,) studied this question.

synapsesocial.com/papers/69f518f8a1676a5934daefc7 https://doi.org/https://doi.org/10.1016/j.jacc.2020.02.065

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