Key result
Flow-based criteria cut indeterminate stress echos, linking intervention in reclassified severe AS to ~50% fewer events.
Why the study?
Do novel transvalvular flow criteria improve diagnostic yield and refine risk stratification compared to conventional criteria in patients with low-gradient aortic stenosis undergoing dobutamine stress echocardiography?
Cohort (n=287)
Do novel transvalvular flow criteria improve diagnostic yield and refine risk stratification compared to conventional criteria in patients with low-gradient aortic stenosis undergoing dobutamine stress echocardiography?
Novel transvalvular flow criteria significantly reduce the rate of indeterminate dobutamine stress echocardiography results and identify patients with low-gradient aortic stenosis who benefit from valve intervention.
Flow criteria may reduce indeterminate DSE in low-gradient AS; leaves open whether reclassification should guide intervention before prospective validation.
BACKGROUND: Guidelines advocate the use of dobutamine stress echocardiography (DSE) in low-gradient aortic stenosis (aortic valve area [AVA] <1 cm 2 with aortic valve mean gradient <40 mm Hg) with reduced left ventricular ejection fraction (<50%) for subsequent patient management. A significant proportion of patients have nondiagnostic DSE (indeterminate aortic stenosis [AS]). METHODS: We aimed to assess the impact of DSE on the management of patients with classical low-gradient aortic stenosis and the use of the newly proposed transvalvular flow–based criteria for AS classification. Accordingly, we retrospectively analyzed 287 patients with classical low-gradient aortic stenosis who underwent DSE. Both the conventional (severe AS when AVA <1 cm 2 and aortic valve mean gradient ≥40 mm Hg, moderate AS when AVA ≥1 cm 2 , and indeterminate AS when AVA <1 cm 2 and aortic valve mean gradient <40 mm Hg during stress) and the proposed combined transvalvular flow criteria (severe AS when AVA <1 cm 2 at a flow rate ≥210 mL/s or projected AVA <1 cm 2 ) were assessed. RESULTS: After DSE, 84 (29%) patients had severe AS, 81 (28%) had moderate AS, and 122 (43%) had indeterminate AS. Over the median follow-up of 12.0 (interquartile range, 5–33) months, more patients with severe AS (73%) underwent aortic valve intervention compared with those with moderate (40%) and indeterminate AS (44%; P <0.001). Use of the newly proposed criteria in the indeterminate AS group improved the proportion of diagnostic tests in the overall population from 57% to 91% and reduced the proportion of indeterminate AS to 9%. Aortic valve intervention was beneficial in patients with reclassified severe AS (HR, 0.50 [95% CI, 0.27–0.92]; P =0.03), whereas the benefit was uncertain in the remaining indeterminate AS group (HR, 0.77 [95% CI, 0.22–2.75]; P =0.69). After aortic valve intervention, patients with conventionally diagnosed severe AS had a better outcome compared with patients with reclassified severe AS (HR, 2.88 [95% CI, 1.34–6.21]; P =0.007). CONCLUSIONS: In this real-world study, the transvalvular flow–based criteria for severe AS markedly reduced the number of indeterminate DSE. Within the indeterminate AS group, patients with reclassified severe AS derived benefit from aortic valve intervention.
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Vamvakidou et al. (2026) conducted a cohort in classical low-gradient aortic stenosis (n=287). Transvalvular flow-based criteria and aortic valve intervention vs. Conventional criteria and conservative management was evaluated on Clinical outcome (benefit of aortic valve intervention) (HR 0.50, 95% CI 0.27-0.92, p=0.03). Transvalvular flow-based criteria reduced indeterminate stress echocardiography to 9%, and aortic valve intervention improved outcomes in reclassified severe AS (HR 0.50; 95% CI 0.27-0.92; P=0.03).
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