Key result
Very low gradient AS shows no adjusted difference in poor TAVR outcomes versus high gradient patients.
Why the study?
While patients with low-flow, low-gradient aortic stenosis benefit from TAVR, data are lacking regarding outcomes in patients with a very low baseline gradient.
Does transcatheter aortic valve replacement improve outcomes in patients with severe aortic stenosis and very low baseline gradients compared to those with low or high gradients?
Cohort (n=1,006)
No
Does transcatheter aortic valve replacement improve outcomes in patients with severe aortic stenosis and very low baseline gradients compared to those with low or high gradients?
Patients with very low gradient severe aortic stenosis undergoing TAVR have significant improvement in health status outcomes, with higher crude 1-year poor outcomes largely attributable to baseline comorbidities rather than the gradient itself.
Answers are grounded in this paper and cite their sources.
Baseline comorbidities largely explain crude outcome differences in very low-gradient TAVR; leaves open gradient-independent risk stratification.
Background While there is evidence that patients with low-flow, low-gradient aortic stenosis (AS) benefit from transcatheter aortic valve replacement (TAVR), data are lacking regarding outcomes of patients with a very low gradient (VLG). Methods In this retrospective, single-center study of patients with severe AS who underwent TAVR, three groups were defined using baseline mean aortic valve gradient: VLG (≤25 mmHg), low gradient (LG, 26–39 mmHg), and high gradient (HG, ≥40 mmHg). The primary outcome was the composite of Kansas City Cardiomyopathy Questionnaire (KCCQ)-12 of <45, decrease in KCCQ-12 of ≥10 compared with baseline, or death at 1 year. Results One-thousand six patients were included: 571 HG, 353 LG, and 82 VLG. The median age was 82.1 years [interquartile range (IQR) 76.3–86.9]; VLG patients had more baseline comorbidities compared with the other groups. The primary outcome was highest at 1 year in the VLG group (VLG, 46.7%; LG, 29.9%; HG, 23.1%; p = 0.002), with no difference between groups after adjustment for baseline characteristics. At baseline, <30% of VLG patients had an excellent or good (50–100) KCCQ-12, whereas more than 75% and 50% had an excellent or good KCCQ-12 at 30-day and 1-year follow-up, respectively. Conclusion Although patients with VLG undergoing TAVR have a higher rate of poor outcomes at 1 year compared with patients with LG and HG severe AS, this difference is largely attributable to baseline comorbidities. Patients with severe AS undergoing TAVR have significant improvement in health status outcomes regardless of resting mean gradient.
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Rahman et al. (2023) conducted a cohort in Severe aortic stenosis (n=1,006). Very low gradient (≤25 mmHg) severe aortic stenosis vs. High gradient (≥40 mmHg) severe aortic stenosis was evaluated on Composite of Kansas City Cardiomyopathy Questionnaire (KCCQ)-12 <45, decrease in KCCQ-12 ≥10 compared with baseline, or death at 1 year (OR 1.80, 95% CI 0.84-3.87, p=0.13). Patients with very low gradient severe aortic stenosis undergoing TAVR had a higher unadjusted rate of poor outcomes at 1 year compared to high gradient patients (46.7% vs 23.1%), but this difference was not significant after adjustment for baseline characteristics (OR 1.80).
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