Discordant low-gradient and high-gradient severe aortic stenosis showed similarly steep PCWP/CO-slopes during exercise, indicating discordant LG AS is a severe AS form.
Does the invasive hemodynamic exercise response differ between discordant low-gradient AS, moderate AS, and high-gradient severe AS in patients with preserved LVEF?
Discordant low-gradient AS and high-gradient severe AS exhibit similar, steeper PCWP/CO-slopes during exercise compared to moderate AS, suggesting discordant LG AS is a severe form of AS with HFpEF physiology.
Absolute Event Rate: 0% vs 0%
BACKGROUND: Guidelines acknowledge that discordant low-gradient (LG) aortic stenosis (AS) may be severe, but verifying this can be challenging. Right heart catheterization during exercise is considered the gold standard for evaluating ventricular hemodynamics. No invasive studies have compared the hemodynamic response of discordant LG and severe AS during exercise. The aim of this observational study was to describe exercise hemodynamics in patients with asymptomatic discordant AS and left ventricular ejection fraction ≥50%. METHODS: Patients with aortic valve area ≤1.5 cm 2 underwent right heart catheterization at rest and during maximal exercise, measuring pulmonary capillary wedge pressure (PCWP), cardiac output (CO), and the PCWP/CO-slope. Patients were stratified into 3 groups: discordant LG AS (aortic valve area ≤1.0 cm 2 and mean gradient 1.0 cm 2 ); and high-gradient (HG) severe AS (aortic valve area ≤1.0 cm 2 and mean gradient ≥40 mm Hg). RESULTS: Among 86 patients, 17 (20%) had discordant LG, 49 (57%) moderate, and 20 (23%) HG severe AS. The median PCWP/CO-slope was significantly steeper in discordant LG (3.3 interquartile range, 2.1–4.3 mm Hg/L/min) and HG severe AS (2.7 1.9–3.4 mm Hg/L per minute) compared with moderate AS (1.9 0.7–2.8 mm Hg/L per minute), P =0.004. In a regression model adjusted for age, sex, and rest PCWP, systemic arterial compliance and AS severity were significantly associated with the PCWP/CO-slope. Furthermore, patients with discordant LG AS had a leftward-upward shift in the PCWP/CO-curve. CONCLUSIONS: Discordant LG and HG severe AS had similar hemodynamic responses to exercise with steeper PCWP/CO-slope than in moderate AS, suggesting that discordant LG AS is a severe form of AS. In addition, the left upwards shift in PCWP/CO-curve for discordant LG compared with HG severe AS indicates that this group also has heart failure with preserved ejection fraction physiology. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04913870 and NCT02395107.
Ali et al. (Mon,) reported a other. Discordant low-gradient and high-gradient severe aortic stenosis showed similarly steep PCWP/CO-slopes during exercise, indicating discordant LG AS is a severe AS form.